Healthcare Provider Details

I. General information

NPI: 1427587054
Provider Name (Legal Business Name): ROSS DAVID BROCKMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS INDUSTRIAL LOOP STE 410
SHREVEPORT LA
71118-3157
US

IV. Provider business mailing address

2508 BERT KOUNS INDUSTRIAL LOOP STE 410
SHREVEPORT LA
71118-3157
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5944
  • Fax: 318-212-5949
Mailing address:
  • Phone: 318-212-5944
  • Fax: 318-212-5949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number331336
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: