MEDICARE: DR. JERRY BECK BLACK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	137953	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4671	OTHER	UT	PEHP

General Provider Information

NPI Number	:	1124062872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY BECK BLACK D.D.S.

Provider Business Mailing Address
First Line	:	8913 RED WILLOW CIR
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1488
Country	:	US
Telephone Number	:	801-255-6742
Fax Number	:	801-255-5170

Provider Business Practice Location Address
First Line	:	1925 E 5600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1351
Country	:	US
Telephone Number	:	801-278-0458
Fax Number	:	801-278-0460

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. JERRY BECK BLACK D.D.S.” Practice Location

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