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General NPI Number Information
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NPI Number | 1386392629
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Entity Type | Individual
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Provider Name | JEREMY DUSTIN BROCK DMD
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Gender | Male
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Dates
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Enumeration Date | 03/15/2022
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Last Update Date | 05/25/2023
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Provider Practice Location Address
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Address Line | 10868 US HIGHWAY 15 501
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-5149
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Country | US
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Telephone | 910-585-0262
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Fax |
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Provider Business Mailing Address
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Address Line | 10868 US 15 501 HWY
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-5149
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12842
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12842
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License Number State | NC
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