Provider Demographics
NPI:1588826341
Name:BLACK, PERRIN JEFFERSON (DDS)
Entity Type:Individual
Prefix:
First Name:PERRIN
Middle Name:JEFFERSON
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 1:3210 SILAS CREEK PARKWAY
Mailing Address - Street 2:UNIT #4 SUITE #4
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-724-1235
Mailing Address - Fax:336-750-0568
Practice Address - Street 1:3210 SILAS CREEK PARKWAY
Practice Address - Street 2:SUITE #4
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-724-1235
Practice Address - Fax:336-750-0568
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6939122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist