Provider Demographics
NPI:1821123589
Name:BLACK, MARCUS D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:D
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 1:2109 S 54TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8195
Mailing Address - Country:US
Mailing Address - Phone:479-464-0900
Mailing Address - Fax:479-464-0708
Practice Address - Street 1:2109 S 54TH ST STE 1
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8195
Practice Address - Country:US
Practice Address - Phone:479-464-0900
Practice Address - Fax:479-464-0708
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR28581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice