Provider Demographics
NPI:1356902878
Name:BLACK, ARTHA JULIA
Entity type:Individual
Prefix:
First Name:ARTHA
Middle Name:JULIA
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5756 TN-153
Mailing Address - Street 2:SUITE 128
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:423-875-9374
Mailing Address - Fax:
Practice Address - Street 1:5756 TN-153
Practice Address - Street 2:SUITE 128
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343
Practice Address - Country:US
Practice Address - Phone:423-875-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist