Provider Demographics
NPI:1659445997
Name:RICHARD C BLACK DDS MS PC
Entity Type:Organization
Organization Name:RICHARD C BLACK DDS MS PC
Other - Org Name:EL PASO ORTHODONTIC ASSOC PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PRACTICIONER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:915-592-5853
Mailing Address - Street 1:1514 ZARAGOSA
Mailing Address - Street 2:STE A-2
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7905
Mailing Address - Country:US
Mailing Address - Phone:915-592-5853
Mailing Address - Fax:915-591-0381
Practice Address - Street 1:1514 ZARAGOSA
Practice Address - Street 2:STE A-2
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7905
Practice Address - Country:US
Practice Address - Phone:915-592-5853
Practice Address - Fax:915-591-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9177596Medicaid
TX169606401Medicaid
TX009005202Medicaid