Provider Demographics
NPI:1619277894
Name:BRIAN S BLACK DDS PLLC
Entity Type:Organization
Organization Name:BRIAN S BLACK DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-695-8000
Mailing Address - Street 1:219 ROCK PRAIRIE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8796
Mailing Address - Country:US
Mailing Address - Phone:979-695-8000
Mailing Address - Fax:979-314-9702
Practice Address - Street 1:219 ROCK PRAIRIE RD STE. 100
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845
Practice Address - Country:US
Practice Address - Phone:979-695-8000
Practice Address - Fax:979-314-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX255091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty