Active NPI
Jacquese Olean Black, DDS
- General Practice Dentistry
- Greensboro, NC
National Provider Identifier
1649387382
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 6204
- Practice address
- 900 Summit Ave
Greensboro, NC 27405-7918 - Phone
- (336) 370-1112
- Fax
- (336) 544-0739
- NPI assigned
- Aug 25, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 6204 | NC | Primary |
Addresses
Primary practice location
900 Summit Ave
Greensboro, NC 27405-7918
Mailing address
2041 Silas Creek Pkwy
Winston Salem, NC 27103-5147
Phone (336) 777-0303
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 90764 | Other | BLUE CROSS BLUE SHIELD NC | |
| 89-90764 | Medicaid | NC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6204 | NC | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Rafael Rivera, Jr., DDS, PLLC | General Practice | Past | Accepting new patients |
| Ballance & Derose DDS PA | General Practice | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- General Practice Dentistry
- Greensboro, NC
- NPI 1053344630
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156464000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1649387382",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2041 SILAS CREEK PKWY",
"city": "WINSTON SALEM",
"state": "NC",
"postal_code": "271035147",
"telephone_number": "336-777-0303",
"fax_number": "336-777-3448"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "900 SUMMIT AVE",
"city": "GREENSBORO",
"state": "NC",
"postal_code": "274057918",
"telephone_number": "336-370-1112",
"fax_number": "336-544-0739"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BLACK",
"first_name": "JACQUESE",
"middle_name": "OLEAN",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-25",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NC",
"license": "6204",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD NC",
"identifier": "90764",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "89-90764",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Greensboro, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.