Provider Demographics
NPI:1336813534
Name:BLACKER, TY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:
Last Name:BLACKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 APPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-8840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4535
Practice Address - Country:US
Practice Address - Phone:580-442-5925
Practice Address - Fax:580-442-7147
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26345122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice