=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891980181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REMY VICTOR BLACK DDS, MBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2007
-----------------------------------------------------
Last Update Date | 09/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 318 W. ALPINE 92707 808 E. MANCHESTER BLVD
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-872-8408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10311
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-872-8408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 44832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------