Provider Demographics
NPI:1437236569
Name:BLACK, JOHN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
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 1:475 TRADE SQ W
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2461
Mailing Address - Country:US
Mailing Address - Phone:937-335-7460
Mailing Address - Fax:937-335-5505
Practice Address - Street 1:475 TRADE SQ W
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2461
Practice Address - Country:US
Practice Address - Phone:937-335-7460
Practice Address - Fax:937-335-5505
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBB56765511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice