Provider Demographics
NPI:1275624959
Name:BLACK, W MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:W
Middle Name:MICHAEL
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 1:1375 E 800 N
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097
Mailing Address - Country:US
Mailing Address - Phone:801-225-2310
Mailing Address - Fax:801-225-6840
Practice Address - Street 1:1375 E 800 N
Practice Address - Street 2:SUITE 103
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097
Practice Address - Country:US
Practice Address - Phone:801-225-2310
Practice Address - Fax:801-225-6840
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14038399221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice