Provider Demographics
NPI:1194954180
Name:BLACK, MISTY MICHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 HAWTHRONE BLVD. STE #102
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278
Mailing Address - Country:US
Mailing Address - Phone:310-376-5252
Mailing Address - Fax:310-376-5757
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:ORAL SURGERY BOX 19
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-668-4675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X1223G0001X
CA596221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XOtherSTUDENT, HEALTH CARE