Provider Demographics
NPI:1225074172
Name:JOEL A BLACK JR DDS PA
Entity Type:Organization
Organization Name:JOEL A BLACK JR DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-765-5421
Mailing Address - Street 1:3314 HEALY DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1408
Mailing Address - Country:US
Mailing Address - Phone:336-765-5421
Mailing Address - Fax:336-760-9952
Practice Address - Street 1:3314 HEALY DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1408
Practice Address - Country:US
Practice Address - Phone:336-765-5421
Practice Address - Fax:336-760-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC90753Medicaid