Provider Demographics
NPI:1700880663
Name:LAWRENCE B BLACK DDS PC AND KEVIN BASS DMD PC PTR
Entity Type:Organization
Organization Name:LAWRENCE B BLACK DDS PC AND KEVIN BASS DMD PC PTR
Other - Org Name:BLACK AND BASS FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-368-1424
Mailing Address - Street 1:410 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2414
Practice Address - Country:US
Practice Address - Phone:215-368-1424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025170L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty