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General NPI Number Information
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NPI Number | 1982967832
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Entity Type | Organization
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Legal Business Name | ELENA BLACK, DDS, PHD, PC
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Dates
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Enumeration Date | 06/15/2012
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Last Update Date | 06/15/2012
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Provider Practice Location Address
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Address Line | 3700 OLD FOREST RD
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City | LYNCHBURG
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State | VA
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Zip | 24501-6900
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Country | US
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Telephone | 434-515-0370
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Fax | 434-338-6552
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Provider Business Mailing Address
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Address Line | 3700 OLD FOREST RD
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City | LYNCHBURG
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State | VA
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Zip | 24501-6900
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Country | US
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Telephone | 434-515-0370
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Fax | 434-338-6552
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELENA BLACK
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Credential | DDS, PHD
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Telephone | 434-515-0370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 0401412779
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License Number State | VA
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