Provider Demographics
NPI:1356638910
Name:BLACK, JENNIFER MICHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-6441
Mailing Address - Country:US
Mailing Address - Phone:712-325-1990
Mailing Address - Fax:712-352-1183
Practice Address - Street 1:902 S 6TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-6441
Practice Address - Country:US
Practice Address - Phone:712-325-1990
Practice Address - Fax:712-352-1183
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice