Provider Demographics
NPI:1013352863
Name:BLACK, KEVIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 65TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77551-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 65TH ST STE A
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-2218
Practice Address - Country:US
Practice Address - Phone:409-744-4551
Practice Address - Fax:409-744-5702
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856252122300000X
TX302911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist