Healthcare Provider Details

I. General information

NPI: 1467422022
Provider Name (Legal Business Name): STEVEN WAYNE BLACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: STEVEN WAYNE BLACK DDS

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 09/09/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MEDICAL GROUP / RAF LAKENHEATH UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

48TH MEDICAL GROUP RAF LAKENHEATH UNIT 5115
APO AE
09461-5115
US

V. Phone/Fax

Practice location:
  • Phone: 163-852-8010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberENDO-526-17
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD-3652-EN
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: