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General NPI Number Information
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NPI Number | 1790987337
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Entity Type | Individual
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Provider Name | GREGORY BLACK DDS
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Gender | Male
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Dates
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Enumeration Date | 06/05/2007
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Last Update Date | 10/29/2012
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Provider Practice Location Address
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Address Line | 203 CHASE DR
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City | HURRICANE
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State | WV
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Zip | 25526-8938
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Country | US
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Telephone | 304-757-7792
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Fax |
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Provider Business Mailing Address
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Address Line | 143 CANDLEWYCK DR
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City | HURRICANE
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State | WV
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Zip | 25526-8813
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Country | US
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Telephone | 304-444-7358
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | WV3055
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License Number State | WV
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