Provider Demographics
NPI:1457525222
Name:BLACK, SAMUEL ARTHUR JR (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ARTHUR
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 1:31 MOUNT VERNON ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1604
Mailing Address - Country:US
Mailing Address - Phone:617-875-3293
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-875-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist