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General NPI Number Information
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NPI Number | 1437383015
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Entity Type | Organization
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Legal Business Name | TY BLACK DDS
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Dates
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Enumeration Date | 05/11/2009
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Last Update Date | 05/11/2009
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Provider Practice Location Address
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Address Line | 5201 S BROADWAY AVE ST 240
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City | TYLER
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State | TX
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Zip | 75703
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Country | US
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Telephone | 903-534-8110
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Fax | 903-534-5510
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Provider Business Mailing Address
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Address Line | 5201 S BROADWAY AVE ST 240
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City | TYLER
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State | TX
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Zip | 75703-3748
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Country | US
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Telephone | 903-534-8110
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Fax | 903-534-5510
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Authorized Official
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Title or Position | OFF MGR
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Name | DANA BLACK
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Credential |
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Telephone | 903-534-8110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 20648
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License Number State | TX
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