Provider Demographics
NPI:1487645487
Name:BLACKWOOD, ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 COUNTY ROAD AA
Mailing Address - Street 2:
Mailing Address - City:QUINTER
Mailing Address - State:KS
Mailing Address - Zip Code:67752-6119
Mailing Address - Country:US
Mailing Address - Phone:785-754-2252
Mailing Address - Fax:
Practice Address - Street 1:501GARFIELD ST.
Practice Address - Street 2:
Practice Address - City:QUINTER
Practice Address - State:KS
Practice Address - Zip Code:67752
Practice Address - Country:US
Practice Address - Phone:785-754-2441
Practice Address - Fax:785-754-2466
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS601891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116736OtherBLUE CROSS BLUE SHIELD
KS1005597OtherDORAL