Provider Demographics
NPI:1861401655
Name:BLACK, ALLEN L (DMD)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 RUSCHMAN DR
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-9273
Mailing Address - Country:US
Mailing Address - Phone:859-441-5562
Mailing Address - Fax:
Practice Address - Street 1:7535 STATE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-2438
Practice Address - Country:US
Practice Address - Phone:513-231-5444
Practice Address - Fax:513-231-8135
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH167231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0423OtherDENTIST