Provider Demographics
NPI:1891980181
Name:BLACK, REMY VICTOR (DDS, MBA)
Entity Type:Individual
Prefix:MR
First Name:REMY
Middle Name:VICTOR
Last Name:BLACK
Suffix:
Gender:M
Credentials:DDS, MBA
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 10311
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-1211
Mailing Address - Country:US
Mailing Address - Phone:310-872-8408
Mailing Address - Fax:
Practice Address - Street 1:318 W. ALPINE 92707
Practice Address - Street 2:808 E. MANCHESTER BLVD
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1914
Practice Address - Country:US
Practice Address - Phone:310-872-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA448321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice