Healthcare Provider Details

I. General information

NPI: 1003916826
Provider Name (Legal Business Name): BENJAMIN LEON SCHROCK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 MEDICAL PARK DR SUITE 201
BILOXI MS
39532-2109
US

IV. Provider business mailing address

1721 MEDICAL PARK DR SUITE 201
BILOXI MS
39532-2109
US

V. Phone/Fax

Practice location:
  • Phone: 228-267-3511
  • Fax:
Mailing address:
  • Phone: 601-529-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3405-06
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number150563
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number106
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: