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General NPI Number Information
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NPI Number | 1831584598
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Entity Type | Organization
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Legal Business Name | STACY BLACK, DDS, PA
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 132 HATCHETT
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City | RUSK
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State | TX
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Zip | 75785
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Country | US
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Telephone | 903-683-5751
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 316
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City | RUSK
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State | TX
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Zip | 75785-0316
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Country | US
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Telephone | 903-683-5751
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Fax |
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Authorized Official
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Title or Position | MEMBER/PRESIDENT
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Name | DR. STACY LEE BLACK
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Credential | DDS
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Telephone | 903-683-5751
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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 | 17132
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License Number State | TX
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