Stacy L Blackmon, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

3673 Issued in SC

Practice address

1100 Village Harbor Dr
Lake Wylie Family Dentistry PA
Lake Wylie, SC 29710

Phone

(803) 831-8856

Fax

(803) 831-8966

NPI assigned

Mar 19, 2007

Last updated

Jul 8, 2007By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in SC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Lake Wylie Family Dentistry PA

  • Dentist
  • Lake Wylie, SC
  • NPI 1437370798
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174262400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1043334766",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 VILLAGE HARBOR DR",
            "city": "LAKE WYLIE",
            "state": "SC",
            "postal_code": "29710",
            "telephone_number": "803-831-8856",
            "fax_number": "803-831-8966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 VILLAGE HARBOR DR",
            "address_2": "LAKE WYLIE FAMILY DENTISTRY PA",
            "city": "LAKE WYLIE",
            "state": "SC",
            "postal_code": "29710",
            "telephone_number": "803-831-8856",
            "fax_number": "803-831-8966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACKMON",
        "first_name": "STACY",
        "middle_name": "L",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-03-19",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "SC",
            "license": "3673",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Barbara Ellen Anslow-Myers
• Barbara E. Anslow-Myers, LLC
• Melisia Ann Bell, DPT
• Peter A. Bertelli, MSN, APRN, PMHNP-BC
• Richard F Biggers, P.T.
• Karin Johana Bock Mullooly
• Geneva Michelle Bolen, OTR/L
• Laura Bradshaw, MS/CCC-SLP
• Brooke Osterhoudt, LLC
• Allison Kay Bull, PA-C

• Dentist in Lake Wylie, SC
• Providers in Lake Wylie, SC by specialty
• Dentist in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.