Bruce A. Blackburn, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

12007761A Issued in IN

Practice address

200 S Dixon Rd
Kokomo, IN 46901-5073

Phone

(765) 456-3015

Fax

(765) 456-1825

NPI assigned

Sep 25, 2006

Last updated

Jul 8, 2007By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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 IN

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

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

{
    "created_epoch": "1159142400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1689775546",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 S DIXON RD",
            "city": "KOKOMO",
            "state": "IN",
            "postal_code": "469015073",
            "telephone_number": "765-456-3015",
            "fax_number": "765-456-1825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 S DIXON RD",
            "city": "KOKOMO",
            "state": "IN",
            "postal_code": "469015073",
            "telephone_number": "765-456-3015",
            "fax_number": "765-456-1825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACKBURN",
        "first_name": "BRUCE",
        "middle_name": "A.",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-09-25",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IN",
            "license": "12007761A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Evan Patrick Bickerstaff
• Allison L Biehle, D.D.S.
• Wanda Bilodeau, RBT
• Jasmine Danielle Binkerd, RBT
• Rachel Lynn Bishir, LPN
• Rebecca Ann Blackburn, RD
• Susan Lynn Blackburn, D.D.S.
• Douglas Blacklidge, DPM
• Amanda Marie Blackmon, DMD
• Kaiden Blane

• General Practice Dentistry in Kokomo, IN
• Providers in Kokomo, IN by specialty
• General Practice Dentistry in Indiana

• 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.