Provider Demographics
NPI:1952680779
Name:BLACK, MARY ROSE CARLOS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY ROSE
Middle Name:CARLOS
Last Name:BLACK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY ROSE
Other - Middle Name:
Other - Last Name:CARLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:7201 RR 2222
Mailing Address - Street 2:#2118
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3208
Mailing Address - Country:US
Mailing Address - Phone:512-537-3301
Mailing Address - Fax:
Practice Address - Street 1:2300 E RANCIER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-3400
Practice Address - Country:US
Practice Address - Phone:512-537-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist