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General NPI Number Information
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NPI Number | 1043991342
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Entity Type | Organization
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Legal Business Name | COREY BLACK DMD PLLC
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Dates
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Enumeration Date | 07/28/2023
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Last Update Date | 07/28/2023
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Provider Practice Location Address
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Address Line | 40 W 117TH ST
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City | NEW YORK
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State | NY
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Zip | 10026-1921
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Country | US
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Telephone | 347-315-3633
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Fax |
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Provider Business Mailing Address
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Address Line | 40 W 117TH ST
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City | NEW YORK
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State | NY
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Zip | 10026-1921
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Country | US
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Telephone | 347-315-3633
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. COREY LAVELLE BLACK
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Credential | DMD
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Telephone | 717-395-3144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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