MEDICARE: BLACKSTONE DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7386388-9922	UT

General Provider Information

NPI Number	:	1700209699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKSTONE DENTAL PLLC

Provider Business Mailing Address
First Line	:	6710 S BLACKSTONE RD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6072
Country	:	US
Telephone Number	:	801-278-0458
Fax Number	:	801-278-0460

Provider Business Practice Location Address
First Line	:	6710 S BLACKSTONE RD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6072
Country	:	US
Telephone Number	:	801-278-0458
Fax Number	:	801-278-0460

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN BLACK
Credential	:
Telephone Number	:	801-278-0458

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	01/28/2014

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