Provider Demographics
NPI:1376632943
Name:BLACK, JOHN THOMAS JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 539
Mailing Address - Street 2:209 S MAIN ST
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-0539
Mailing Address - Country:US
Mailing Address - Phone:662-489-7768
Mailing Address - Fax:877-698-4592
Practice Address - Street 1:209 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-3319
Practice Address - Country:US
Practice Address - Phone:662-489-7768
Practice Address - Fax:877-698-4592
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2066-841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice