Provider Demographics
NPI:1831584598
Name:STACY BLACK, DDS, PA
Entity type:Organization
Organization Name:STACY BLACK, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-683-5751
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-0316
Mailing Address - Country:US
Mailing Address - Phone:903-683-5751
Mailing Address - Fax:
Practice Address - Street 1:132 HATCHETT
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785
Practice Address - Country:US
Practice Address - Phone:903-683-5751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty