Provider Demographics
NPI:1962512368
Name:BLACK, DORIS J (DDS)
Entity type:Individual
Prefix:DR
First Name:DORIS
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718A WEST CORBETT AVENUE
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584
Mailing Address - Country:US
Mailing Address - Phone:910-326-3611
Mailing Address - Fax:910-326-1122
Practice Address - Street 1:200 718A WEST CORBETT AVENUE
Practice Address - Street 2:
Practice Address - City:SWANSBORO
Practice Address - State:NC
Practice Address - Zip Code:28584
Practice Address - Country:US
Practice Address - Phone:910-326-3611
Practice Address - Fax:910-326-1122
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC48771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0269COtherBCBS
NC3224OtherDELTA
NC8990759Medicaid
NC0269COtherBCBS