Healthcare Provider Details

I. General information

NPI: 1336211614
Provider Name (Legal Business Name): ERIC SCOTT BROCKMAN DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 CASTOR AVE STE 300
PHILADELPHIA PA
19152-4027
US

IV. Provider business mailing address

635 MEADOWBROOK DR APT 635
HUNTINGDON VALLEY PA
19006-6913
US

V. Phone/Fax

Practice location:
  • Phone: 215-722-4290
  • Fax: 215-722-3734
Mailing address:
  • Phone: 206-498-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number00007825
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1001067-15
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number11876
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS028499L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: