Provider Demographics
NPI:1851696413
Name:BLACK, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E 5TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1641
Mailing Address - Country:US
Mailing Address - Phone:810-406-4912
Mailing Address - Fax:810-424-6029
Practice Address - Street 1:G3375 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1277
Practice Address - Country:US
Practice Address - Phone:810-743-6830
Practice Address - Fax:810-743-7102
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014907124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist