Provider Demographics
NPI:1891015996
Name:BLACK, BRIAN SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
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:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:TX
Mailing Address - Zip Code:77445-0095
Mailing Address - Country:US
Mailing Address - Phone:832-675-1242
Mailing Address - Fax:
Practice Address - Street 1:219 ROCK PRAIRIE RD
Practice Address - Street 2:STE. 100
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8796
Practice Address - Country:US
Practice Address - Phone:979-695-8000
Practice Address - Fax:979-314-9702
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX255091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice