Provider Demographics
NPI:1689771677
Name:BLACK & BLACK DENTAL LLC
Entity Type:Organization
Organization Name:BLACK & BLACK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:III
Authorized Official - Credentials:DDA
Authorized Official - Phone:717-464-3223
Mailing Address - Street 1:2600 WILLOW STREET PIKE S
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584-9377
Mailing Address - Country:US
Mailing Address - Phone:717-464-3223
Mailing Address - Fax:717-464-4150
Practice Address - Street 1:2600 WILLOW STREET PIKE S
Practice Address - Street 2:
Practice Address - City:WILLOW STREET
Practice Address - State:PA
Practice Address - Zip Code:17584-9377
Practice Address - Country:US
Practice Address - Phone:717-464-3223
Practice Address - Fax:717-464-4150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty