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General NPI Number Information
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NPI Number | 1619277894
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Entity Type | Organization
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Legal Business Name | BRIAN S BLACK DDS PLLC
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Dates
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Enumeration Date | 10/22/2010
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 219 ROCK PRAIRIE RD STE. 100
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City | COLLEGE STATION
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State | TX
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Zip | 77845
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Country | US
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Telephone | 979-695-8000
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Fax | 979-314-9702
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Provider Business Mailing Address
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Address Line | 219 ROCK PRAIRIE RD STE 100
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City | COLLEGE STATION
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State | TX
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Zip | 77845-8796
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Country | US
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Telephone | 979-695-8000
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Fax | 979-314-9702
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRIAN SCOTT BLACK
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Credential | DDS
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Telephone | 979-695-8000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 25509
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License Number State | TX
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