Provider Demographics
NPI:1710419635
Name:BLACK, EMILY PETTIT (DDS)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:PETTIT
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 OVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-4825
Mailing Address - Country:US
Mailing Address - Phone:304-610-6542
Mailing Address - Fax:
Practice Address - Street 1:157 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:WESTOVER
Practice Address - State:WV
Practice Address - Zip Code:26501
Practice Address - Country:US
Practice Address - Phone:304-296-1721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice