Healthcare Provider Details

I. General information

NPI: 1720509482
Provider Name (Legal Business Name): JASON R. BROCK DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17150 EL CAMINO REAL
HOUSTON TX
77058-2738
US

IV. Provider business mailing address

818A YALE ST
HOUSTON TX
77007-1538
US

V. Phone/Fax

Practice location:
  • Phone: 281-461-7470
  • Fax:
Mailing address:
  • Phone: 323-273-9549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number28465
License Number StateTX

VIII. Authorized Official

Name: DR. JASON BROCK
Title or Position: OWNER
Credential: DDS
Phone: 281-461-7470