Provider Demographics
NPI:1174530091
Name:BLACK, STEVEN W (DDS)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:W
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:PO BOX 1891
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14795 SW MURRAY SCHOLLS DR
Practice Address - Street 2:STE 119
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9713
Practice Address - Country:US
Practice Address - Phone:503-524-0524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD67361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD6736OtherOREGON DENTAL LICENSE