Provider Demographics
NPI:1255409819
Name:BLACK, DOROTHY ANNE (RDH)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:ANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431
Mailing Address - Country:US
Mailing Address - Phone:815-254-9565
Mailing Address - Fax:
Practice Address - Street 1:406 BOUGHTON RD
Practice Address - Street 2:B
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:630-759-8940
Practice Address - Fax:603-759-9392
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist