MEDICARE: WILLIAM J. BLACK DDS, INC

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	1223G0001X	General Practice Dentistry	40140	CA

General Provider Information

NPI Number	:	1336460088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAM J. BLACK DDS, INC

Provider Business Mailing Address
First Line	:	2925 ELVERTA RD
Second Line	:
City	:	ANTELOPE
State	:	CA
Zip	:	95843-9106
Country	:	US
Telephone Number	:	916-331-6288
Fax Number	:	916-331-0760

Provider Business Practice Location Address
First Line	:	2925 ELVERTA RD
Second Line	:
City	:	ANTELOPE
State	:	CA
Zip	:	95843-9106
Country	:	US
Telephone Number	:	916-331-6288
Fax Number	:	916-331-0760

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WILLIAM JOHN BLACK
Credential	:	DDS
Telephone Number	:	916-331-6288

Provider Enumeration Date	:	06/17/2010
Last Update Date	:	06/17/2010

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