Healthcare Provider Details

I. General information

NPI: 1073211637
Provider Name (Legal Business Name): DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

869 OAKWOOD RD
CHARLESTON WV
25314-2057
US

IV. Provider business mailing address

103 STATION PLACE WAY
HURRICANE WV
25526-8747
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-1092
  • Fax:
Mailing address:
  • Phone: 304-720-7819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: LESLEY MARIE COYNER
Title or Position: ACCTS RECEIVABLE MANAGER
Credential:
Phone: 304-720-7819