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General NPI Number Information
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NPI Number | 1720734684
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Entity Type | Organization
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Legal Business Name | DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC
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Dates
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Enumeration Date | 03/01/2022
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Last Update Date | 05/30/2025
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Provider Practice Location Address
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Address Line | 895 E WASHINGTON AVE
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City | VINTON
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State | VA
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Zip | 24179-2105
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Country | US
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Telephone | 304-425-8220
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Fax |
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Provider Business Mailing Address
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Address Line | 103 STATION PLACE WAY
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City | HURRICANE
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State | WV
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Zip | 25526-8747
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Country | US
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Telephone | 304-720-7819
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | LESLEY MARIE COYNER
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Credential |
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Telephone | 304-720-7819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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