Provider Demographics
NPI:1376953901
Name:SAMUEL BLACK, DMD, PHD, PC
Entity Type:Organization
Organization Name:SAMUEL BLACK, DMD, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS, DMD, PHD
Authorized Official - Phone:617-875-3293
Mailing Address - Street 1:3700 OLD FOREST RD.
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501
Mailing Address - Country:US
Mailing Address - Phone:434-515-0370
Mailing Address - Fax:434-338-6552
Practice Address - Street 1:3700 OLD FOREST RD.
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-515-0370
Practice Address - Fax:434-338-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014124261223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty