=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508010497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD E BLACK DDS,MS,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2008
-----------------------------------------------------
Last Update Date | 11/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3015 CRENSHAW BLVD SUITE C
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90016-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-734-1534
-----------------------------------------------------
Fax | 323-734-4693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3015 CRENSHAW BLVD SUITE C
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90016-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-734-1534
-----------------------------------------------------
Fax | 323-734-4693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MARIA ORELLANA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-734-1534
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 17879
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------