Provider Demographics
NPI:1528041399
Name:BLACK, BYRON HAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:HAL
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 1:102 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271
Mailing Address - Country:US
Mailing Address - Phone:304-514-5500
Mailing Address - Fax:304-514-5504
Practice Address - Street 1:102 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-1164
Practice Address - Country:US
Practice Address - Phone:304-514-5500
Practice Address - Fax:304-514-5504
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20811223S0112X
WV591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0138164000Medicaid
WV0138164000Medicaid
WVBL0454874Medicare ID - Type Unspecified
WV0138164000Medicaid