Healthcare Provider Details

I. General information

NPI: 1346201183
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: 03/31/2006
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 VIRGINIA ST E
CHARLESTON WV
25301
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: 304-345-5080
Mailing address:
  • Phone: 304-720-7819
  • Fax: 304-345-5080

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: CREDENTIALING
Credential:
Phone: 304-720-7819