Provider Demographics
NPI:1992927115
Name:BLACK, ANTHONY J (DDS)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:BLACK
Suffix:
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 1:12950 HIGHLAND CROSSING DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-5888
Mailing Address - Country:US
Mailing Address - Phone:703-787-9670
Mailing Address - Fax:
Practice Address - Street 1:12950 HIGHLAND CROSSING DR
Practice Address - Street 2:SUITE F
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-5888
Practice Address - Country:US
Practice Address - Phone:703-787-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014107491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice