Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 10496 | TX |
NPI | 1003870601 |
---|---|
Provider Name | Dr. George Maury Blackburn |
First Address | Austin, TX 78750-1867 |
Second Address | Austin, TX 78750-1867 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2006 |
Last Update Date | 08/07/2007 |