Organization
JERRY B. BLACK, DDS, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JERRY BECK BLACK D.D.S. (PRESIDENT)
(801) 278-0458
Entity
Organization
Contact information
Practice address
1925 E 5600 S, SALT LAKE CITY, UT 84121-1351
(801) 278-0458
(801) 278-0460
Mailing address
8913 RED WILLOW CIR, SANDY, UT 84093-1488
(801) 255-6742
(801) 255-5170
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
137953
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4671
PEHP
UT
Enumeration date
06/12/2006
Last updated
08/22/2020
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