MEDICARE: MR. WILLIAM JOHN BLACK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	40140	CA

General Provider Information

NPI Number	:	1043251176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM JOHN BLACK D.D.S.

Provider Business Mailing Address
First Line	:	2925 ELVERTA RD
Second Line	:
City	:	ANTELOPE
State	:	CA
Zip	:	95843-9106
Country	:	US
Telephone Number	:	916-331-6288
Fax Number	:	916-331-0760

Provider Business Practice Location Address
First Line	:	2925 ELVERTA RD
Second Line	:
City	:	ANTELOPE
State	:	CA
Zip	:	95843-9106
Country	:	US
Telephone Number	:	916-331-6288
Fax Number	:	916-331-0760

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	07/08/2007

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1235245168 — MR. VIMAL AMRAL DULABH DDS
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