Provider Demographics
NPI:1184896078
Name:BLACK, RICHARD C (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
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 1:1514 ZARAGOSA RD
Mailing Address - Street 2:STE A-2
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7905
Mailing Address - Country:US
Mailing Address - Phone:915-592-5853
Mailing Address - Fax:915-591-0381
Practice Address - Street 1:1514 ZARAGOSA RD
Practice Address - Street 2:STE. A-2
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7905
Practice Address - Country:US
Practice Address - Phone:915-592-5853
Practice Address - Fax:915-591-0381
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009005202Medicaid
NM9177596Medicaid
TX169606401Medicaid