Provider Demographics
NPI:1801925607
Name:BLACK, JOHN R
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4347 RICE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-1335
Mailing Address - Country:US
Mailing Address - Phone:808-245-3582
Mailing Address - Fax:
Practice Address - Street 1:4347 RICE ST STE 202
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1335
Practice Address - Country:US
Practice Address - Phone:808-245-3582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI09211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI06698901Medicaid
ID0921OtherHDS INSURANCE
HI00087387OtherHMSA