Provider Demographics
NPI:1578017505
Name:BLACK, JHARED (DMD)
Entity Type:Individual
Prefix:
First Name:JHARED
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3677 SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1461
Mailing Address - Country:US
Mailing Address - Phone:708-481-2288
Mailing Address - Fax:
Practice Address - Street 1:3677 SAUK TRL
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1461
Practice Address - Country:US
Practice Address - Phone:708-481-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030918122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL455618926Medicaid