Provider Demographics
NPI:1295097699
Name:RICHARD F. BLACK, DMD., MPH, PC
Entity type:Organization
Organization Name:RICHARD F. BLACK, DMD., MPH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:570-724-2141
Mailing Address - Street 1:15 MEADE STREET
Mailing Address - Street 2:SUITE U5
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901
Mailing Address - Country:US
Mailing Address - Phone:570-724-2141
Mailing Address - Fax:570-724-3942
Practice Address - Street 1:15 MEADE ST
Practice Address - Street 2:SUITE U5
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1813
Practice Address - Country:US
Practice Address - Phone:570-724-2141
Practice Address - Fax:570-724-3942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025700L261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010875620001Medicaid
PA141040OtherPA BLUE SHIELD
PA141040OtherUNITED CONCORDIA
PA0010875620001Medicaid
PA141040Medicare PIN