Provider Demographics
NPI:1427112978
Name:BLACK, JOEL A JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:A
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 1:3314 HEALY DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1408
Mailing Address - Country:US
Mailing Address - Phone:336-765-5421
Mailing Address - Fax:336-760-9952
Practice Address - Street 1:3314 HEALY DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1408
Practice Address - Country:US
Practice Address - Phone:336-765-5421
Practice Address - Fax:336-760-9952
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990753Medicaid
NC1225074172Other'ORGANIZATION' NPI
NC8990753Medicaid