Provider Demographics
NPI:1912158064
Name:BLACK, ALAN HOWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:HOWARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3524
Mailing Address - Country:US
Mailing Address - Phone:631-667-3835
Mailing Address - Fax:
Practice Address - Street 1:240 PATCHOGUE YAPHANK RD
Practice Address - Street 2:SUITE 104
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4868
Practice Address - Country:US
Practice Address - Phone:631-289-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035629-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice