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General NPI Number Information
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NPI Number | 1487946992
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Entity Type | Organization
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Legal Business Name | MISTY MICHELLE BLACK DDS INC
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Dates
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Enumeration Date | 05/03/2011
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Last Update Date | 05/03/2011
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Provider Practice Location Address
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Address Line | 3015 CRENSHAW BLVD # C
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City | LOS ANGELES
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State | CA
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Zip | 90016-4264
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Country | US
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Telephone | 323-734-1534
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Fax |
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Provider Business Mailing Address
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Address Line | 3015 CRENSHAW BLVD # C
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City | LOS ANGELES
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State | CA
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Zip | 90016-4264
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Country | US
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Telephone | 323-734-1534
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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. MISTY MICHELLE BLACK
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Credential | DDS
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Telephone | 323-734-1534
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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 | 59622
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License Number State | CA
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