Healthcare Provider Details

I. General information

NPI: 1982967832
Provider Name (Legal Business Name): ELENA BLACK, DDS, PHD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 OLD FOREST RD
LYNCHBURG VA
24501-6900
US

IV. Provider business mailing address

3700 OLD FOREST RD
LYNCHBURG VA
24501-6900
US

V. Phone/Fax

Practice location:
  • Phone: 434-515-0370
  • Fax: 434-338-6552
Mailing address:
  • Phone: 434-515-0370
  • Fax: 434-338-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0401412779
License Number StateVA

VIII. Authorized Official

Name: DR. ELENA BLACK
Title or Position: PRESIDENT
Credential: DDS, PHD
Phone: 434-515-0370