Provider Demographics
NPI:1437394467
Name:BLACK, ANGELA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
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:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1810 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6117
Practice Address - Country:US
Practice Address - Phone:870-972-8075
Practice Address - Fax:870-972-8240
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45431223G0001X
AR37021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice