Provider Demographics
NPI:1083843544
Name:BLACK, NAN MONROE (DDS)
Entity Type:Individual
Prefix:DR
First Name:NAN
Middle Name:MONROE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:NAN
Other - Middle Name:ELIZABETH
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:14810 CANTRELL RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4681
Mailing Address - Country:US
Mailing Address - Phone:501-673-3905
Mailing Address - Fax:
Practice Address - Street 1:14810 CANTRELL RD STE 150
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4681
Practice Address - Country:US
Practice Address - Phone:501-673-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3580-11122300000X
AR41601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist