Healthcare Provider Details

I. General information

NPI: 1740021013
Provider Name (Legal Business Name): AUSTIN MICHAEL BROCK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 W HAPPY VALLEY RD
GLENDALE AZ
85310-3295
US

IV. Provider business mailing address

8478 W MONONA LN
PEORIA AZ
85382-7418
US

V. Phone/Fax

Practice location:
  • Phone: 623-533-4895
  • Fax:
Mailing address:
  • Phone: 360-477-9288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012158
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012158
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: