Provider Demographics
NPI:1487192407
Name:PAUL R BLACK DDS PC
Entity Type:Organization
Organization Name:PAUL R BLACK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-359-8271
Mailing Address - Street 1:2525 KIMBERLY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3538
Mailing Address - Country:US
Mailing Address - Phone:563-359-8271
Mailing Address - Fax:563-359-8272
Practice Address - Street 1:2525 KIMBERLY RD STE 3
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3538
Practice Address - Country:US
Practice Address - Phone:563-359-8271
Practice Address - Fax:563-359-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA70601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty