Provider Demographics
NPI:1164558359
Name:BLACK, LARRY MILTON JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:MILTON
Last Name:BLACK
Suffix:JR
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 1:1306 E SCREVEN ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-2318
Mailing Address - Country:US
Mailing Address - Phone:229-263-8700
Mailing Address - Fax:229-263-4212
Practice Address - Street 1:1306 E SCREVEN ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-2318
Practice Address - Country:US
Practice Address - Phone:229-263-8700
Practice Address - Fax:229-263-4212
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice