Provider Demographics
NPI:1043991342
Name:COREY BLACK DMD PLLC
Entity Type:Organization
Organization Name:COREY BLACK DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:LAVELLE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-395-3144
Mailing Address - Street 1:40 W 117TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1921
Mailing Address - Country:US
Mailing Address - Phone:347-315-3633
Mailing Address - Fax:
Practice Address - Street 1:40 W 117TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1921
Practice Address - Country:US
Practice Address - Phone:347-315-3633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental