Healthcare Provider Details

I. General information

NPI: 1407812415
Provider Name (Legal Business Name): DENNIS D BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST
MEMPHIS TN
38105
US

IV. Provider business mailing address

51 N DUNLAP ST
MEMPHIS TN
38105-4625
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-6760
  • Fax:
Mailing address:
  • Phone: 901-287-6760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number13581
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: