Provider Demographics
NPI:1326408162
Name:BLACK, SEPTEMBER (RDH)
Entity Type:Individual
Prefix:
First Name:SEPTEMBER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 CIRQUE WAY
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5315
Mailing Address - Country:US
Mailing Address - Phone:720-382-3940
Mailing Address - Fax:
Practice Address - Street 1:25 S LOT AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4037
Practice Address - Country:US
Practice Address - Phone:970-249-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH 002023562124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist