Provider Demographics
NPI:1003870601
Name:BLACKBURN, GEORGE MAURY (DMD, FAGD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MAURY
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12505 HYMEADOW DR
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1867
Mailing Address - Country:US
Mailing Address - Phone:512-258-3627
Mailing Address - Fax:512-258-0755
Practice Address - Street 1:12505 HYMEADOW DR
Practice Address - Street 2:SUITE 2D
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1867
Practice Address - Country:US
Practice Address - Phone:512-258-3627
Practice Address - Fax:512-258-0755
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist