MEDICARE: DR. GEORGE PETER BLACK D.M.D.

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	DS027891L	PA

General Provider Information

NPI Number	:	1962443937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE PETER BLACK D.M.D.

Provider Business Mailing Address
First Line	:	309 N MAIN ST
Second Line	:
City	:	ARCHBALD
State	:	PA
Zip	:	18403-1908
Country	:	US
Telephone Number	:	570-876-3012
Fax Number	:	570-876-3936

Provider Business Practice Location Address
First Line	:	309 N MAIN ST
Second Line	:
City	:	ARCHBALD
State	:	PA
Zip	:	18403-1908
Country	:	US
Telephone Number	:	570-876-3012
Fax Number	:	570-876-3936

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	07/08/2007

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