Provider Demographics
NPI:1558556209
Name:BLACK, STEPHEN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
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 1:3637 GRAPE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5715
Mailing Address - Country:US
Mailing Address - Phone:310-733-7116
Mailing Address - Fax:
Practice Address - Street 1:1231 CANDELARIA RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-2767
Practice Address - Country:US
Practice Address - Phone:505-843-7581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist