MEDICARE: ROMNEY R. BLACK DDS PC

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	122300000X	Dentist	5132937	UT

General Provider Information

NPI Number	:	1215958244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROMNEY R. BLACK DDS PC

Provider Business Mailing Address
First Line	:	6575 SO. REDWOOD RD. #275
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84123
Country	:	US
Telephone Number	:	801-716-2500
Fax Number	:	801-716-2503

Provider Business Practice Location Address
First Line	:	4370 S REDWOOD RD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84123-2223
Country	:	US
Telephone Number	:	801-969-1802
Fax Number	:	801-966-6853

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	ROMNEY RICHARD BLACK
Credential	:	D.D.S.
Telephone Number	:	801-969-1802

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	05/27/2014

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