MEDICARE: RICHARD C BLACK DDS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	11053	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184896078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD C BLACK DDS

Provider Business Mailing Address
First Line	:	1514 ZARAGOSA RD
Second Line	:	STE A-2
City	:	EL PASO
State	:	TX
Zip	:	79936-7905
Country	:	US
Telephone Number	:	915-592-5853
Fax Number	:	915-591-0381

Provider Business Practice Location Address
First Line	:	1514 ZARAGOSA RD
Second Line	:	STE. A-2
City	:	EL PASO
State	:	TX
Zip	:	79936-7905
Country	:	US
Telephone Number	:	915-592-5853
Fax Number	:	915-591-0381

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

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	03/26/2009

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