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General NPI Number Information
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NPI Number | 1710419635
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Entity Type | Individual
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Provider Name | EMILY PETTIT BLACK DDS
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Gender | Female
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Dates
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Enumeration Date | 03/30/2017
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Last Update Date | 07/08/2018
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Provider Practice Location Address
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Address Line | 157 HOLLAND AVE
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City | WESTOVER
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State | WV
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Zip | 26501
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Country | US
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Telephone | 304-296-1721
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Fax |
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Provider Business Mailing Address
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Address Line | 440 OVERHILL ST
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City | MORGANTOWN
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State | WV
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Zip | 26505-4825
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Country | US
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Telephone | 304-610-6542
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4266
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License Number State | WV
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