Provider Demographics
NPI:1760847123
Name:JOHN J BLACK DDS, INC.
Entity Type:Organization
Organization Name:JOHN J BLACK DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-739-7721
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:DOVE CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:81324-0871
Mailing Address - Country:US
Mailing Address - Phone:970-739-7721
Mailing Address - Fax:
Practice Address - Street 1:18 S BEECH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3744
Practice Address - Country:US
Practice Address - Phone:970-565-4702
Practice Address - Fax:970-565-1979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty