Provider Demographics
NPI:1396856571
Name:BLACK, JOEL LESLIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:LESLIE
Last Name:BLACK
Suffix:
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 1:277 CABOT ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4525
Mailing Address - Country:US
Mailing Address - Phone:978-927-1750
Mailing Address - Fax:978-922-0143
Practice Address - Street 1:277 CABOT ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4525
Practice Address - Country:US
Practice Address - Phone:978-927-1750
Practice Address - Fax:978-922-0143
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA99681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice