JETHRO BLACK JR Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****59

License Status

NOT RENEWED

Business

First Name

JETHRO

Last Name

BLACK JR

Business Name

JETHRO BLACK JR

Original Issue Date

06/19/1990

Effective Date

06/19/1990

Expiration Date

09/30/1996

City

VENICE

State

Zip

62090

County

MADISON

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

10/13/2005