MEDICARE: JOHN E BROCK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	3308	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	129	OTHER	WV	SPECIALIST, ORAL AND MAXILLOFACIAL SURGERY
2	3308	OTHER	WV	WV DENTAL LIC.
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	10439	OTHER	KY	KY DENTAL LICENSE

General Provider Information

NPI Number	:	1376555227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN E BROCK D.D.S.

Provider Business Mailing Address
First Line	:	103 STATION PLACE WAY
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-8747
Country	:	US
Telephone Number	:	304-720-7819
Fax Number	:

Provider Business Practice Location Address
First Line	:	100A PRESTIGE PARK DR
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-8417
Country	:	US
Telephone Number	:	304-757-0272
Fax Number	:	304-757-0273

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	09/26/2022

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Directions to “ JOHN E BROCK D.D.S.” Practice Location

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