Provider Demographics
NPI:1407586274
Name:BLACK, CHRISTIAN (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 OLEANDER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5752
Mailing Address - Country:US
Mailing Address - Phone:843-492-6724
Mailing Address - Fax:
Practice Address - Street 1:4610 OLEANDER DR STE 201
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5752
Practice Address - Country:US
Practice Address - Phone:843-492-6724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.10222122300000X
SC109381223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist