Dental Board of California
Licensing details for: 59622
Name: BLACK, MISTY M
License Type: Dentist
Primary Status: Current - Active
Secondary Status: Licensure by Residency
Method of Application: Licensure by Residency
License Relationships
AO to DDS or OMS (Owners)
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Additional Office Permit
Name: BLACK AND TO DENTAL CORPORATION
License/Registration Type: Additional Office Permit
License Number: 79333 Primary Status: Current - Active
Address :
1509 HAWTHORNE BLVD SUITE 102
REDONDO BEACH CA 90278
LOS ANGELES COUNTY
CS to DDS, OMS, or SP
License/Registration Role: Must hold an active Dental License, Oral Maxillofacial Surgery Permit, or Special Permit
Related Party Role: Conscious Sedation Permit
Name: BLACK, MISTY M
License/Registration Type: Conscious Sedation Permit
License Number: 727 Primary Status: Cancelled
Address :
5425 SHENANDOAH
LOS ANGELES CA 90056
LOS ANGELES COUNTY
FNP to DDS or OMS
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Fictitious Name Permit
Name: BEACH CITY DENTAL GROUP BLACK AND TO DENTAL CORPORATION
License/Registration Type: Fictitious Name Permit
License Number: 13515 Primary Status: Current - Active
Address :
1509 HAWTHORNE BLVD STE 102
REDONDO BEACH CA 90278
LOS ANGELES COUNTY
