Basic Information
| Provider Information | |||||||||
| NPI: | 1942273396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MCHUGH BLVD | ||||||||
| Address2: | 2D DEN BN/NDC | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285472511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MCHUGH BLVD | ||||||||
| Address2: | 2D DEN BN/NDC | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285472511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0700X | 0401008403 | VA | Y | Dental Providers | Dentist | Prosthodontics |
No ID Information.