Healthcare Provider Details

I. General information

NPI: 1497740427
Provider Name (Legal Business Name): KURT S. BLACK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2356 NW PROFESSIONAL DR
CORVALLIS OR
97330-3881
US

IV. Provider business mailing address

2356 NW PROFESSIONAL DR
CORVALLIS OR
97330-3881
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-0144
  • Fax: 541-754-0145
Mailing address:
  • Phone: 541-754-0144
  • Fax: 541-754-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6925
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: