Provider Demographics
NPI:1558379651
Name:BLACK, KATHLEEN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
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:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:832-548-5000
Mailing Address - Fax:
Practice Address - Street 1:1415 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-2602
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20-2421646OtherTAX ID #