Provider Demographics
NPI:1497718969
Name:BLACKER, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:BLACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11208 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64137-2504
Mailing Address - Country:US
Mailing Address - Phone:816-763-8400
Mailing Address - Fax:816-765-8403
Practice Address - Street 1:11208 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64137-2504
Practice Address - Country:US
Practice Address - Phone:816-763-8400
Practice Address - Fax:816-765-8403
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice