Provider Demographics
NPI:1790819381
Name:BLACK, EMMETT WHEELESS JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EMMETT
Middle Name:WHEELESS
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-5202
Mailing Address - Country:US
Mailing Address - Phone:478-272-6316
Mailing Address - Fax:478-275-4340
Practice Address - Street 1:526 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5202
Practice Address - Country:US
Practice Address - Phone:478-272-6316
Practice Address - Fax:478-275-4340
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0081171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice