Provider Demographics
NPI:1427101567
Name:BLACK, PAUL RALPH JR (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RALPH
Last Name:BLACK
Suffix:JR
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 1:2525 KIMBERLY RD
Mailing Address - Street 2:SUITE#3
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3538
Mailing Address - Country:US
Mailing Address - Phone:563-359-8271
Mailing Address - Fax:563-359-8272
Practice Address - Street 1:2525 KIMBERLY RD
Practice Address - Street 2:SUITE#3
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3538
Practice Address - Country:US
Practice Address - Phone:563-359-8271
Practice Address - Fax:563-359-8272
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist