Provider Demographics
NPI:1124062872
Name:BLACK, JERRY BECK (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:BECK
Last Name:BLACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8913 RED WILLOW CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1488
Mailing Address - Country:US
Mailing Address - Phone:801-255-6742
Mailing Address - Fax:801-255-5170
Practice Address - Street 1:1925 E 5600 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1351
Practice Address - Country:US
Practice Address - Phone:801-278-0458
Practice Address - Fax:801-278-0460
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT137953122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4671OtherPEHP