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General NPI Number Information
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NPI Number | 1699094151
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Entity Type | Individual
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Provider Name | BROCK PHILIPS DMD
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Gender | Male
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Dates
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Enumeration Date | 05/24/2010
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Last Update Date | 11/16/2011
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Provider Practice Location Address
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Address Line | 4540 SOUTHSIDE BLVD SUITE 801
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5492
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Country | US
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Telephone | 904-642-2010
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Fax | 904-642-8282
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Provider Business Mailing Address
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Address Line | 4540 SOUTHSIDE BLVD SUITE 801
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5492
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Country | US
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Telephone | 904-642-2010
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Fax | 904-642-8282
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN14354
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License Number State | FL
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