MEDICARE: DR. JEREMY DUSTIN BROCK DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12842	NC
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223G0001X	General Practice Dentistry	12842	NC

General Provider Information

NPI Number	:	1386392629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY DUSTIN BROCK DMD

Provider Business Mailing Address
First Line	:	10868 US 15 501 HWY
Second Line	:
City	:	SOUTHERN PINES
State	:	NC
Zip	:	28387-5149
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10868 US HIGHWAY 15 501
Second Line	:
City	:	SOUTHERN PINES
State	:	NC
Zip	:	28387-5149
Country	:	US
Telephone Number	:	910-585-0262
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2022
Last Update Date	:	05/25/2023

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