Provider Demographics
NPI:1790987337
Name:BLACK, GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 CANDLEWYCK DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8813
Mailing Address - Country:US
Mailing Address - Phone:304-444-7358
Mailing Address - Fax:
Practice Address - Street 1:203 CHASE DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8938
Practice Address - Country:US
Practice Address - Phone:304-757-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV3055122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL4247152Medicare PIN