Provider Demographics
NPI:1306286034
Name:BLACK, MARK JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
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 1:1717 BROADMOOR DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5933
Mailing Address - Country:US
Mailing Address - Phone:217-359-1541
Mailing Address - Fax:
Practice Address - Street 1:1717 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5933
Practice Address - Country:US
Practice Address - Phone:217-359-1541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist