Provider Demographics
NPI:1316124555
Name:BLACK, RICHARD MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:BLACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-942-4040
Mailing Address - Fax:760-918-6890
Practice Address - Street 1:317 N EL CAMINO REAL
Practice Address - Street 2:SUITE 203
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2811
Practice Address - Country:US
Practice Address - Phone:760-942-4040
Practice Address - Fax:760-918-6890
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics