Provider Demographics
NPI:1598169831
Name:BLACK, SARAH NICHOLE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:NICHOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 3RD ST
Mailing Address - Street 2:215 E. 3RD ST
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 E 3RD ST
Practice Address - Street 2:215 E. 3RD ST
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-1661
Practice Address - Country:US
Practice Address - Phone:417-674-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007015640124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist