Provider Demographics
NPI:1073547170
Name:BLACK, JAMES EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:BLACK
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 1:250 EAST WENTWORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3525
Mailing Address - Country:US
Mailing Address - Phone:651-455-1577
Mailing Address - Fax:651-455-8641
Practice Address - Street 1:250 EAST WENTWORTH AVENUE
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3525
Practice Address - Country:US
Practice Address - Phone:651-455-1577
Practice Address - Fax:651-455-8641
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7401122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist