Provider Demographics
NPI:1053544650
Name:BLACK, BRANDON DUSTIN (DC)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:DUSTIN
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S MACARTHUR BLVD
Mailing Address - Street 2:SUITE 105-127
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4216
Mailing Address - Country:US
Mailing Address - Phone:469-323-3909
Mailing Address - Fax:
Practice Address - Street 1:2928 INWOOD RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7518
Practice Address - Country:US
Practice Address - Phone:469-323-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-29
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor