MEDICARE: DR. BROCK CHARLES MCKINLEY

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	9658	CO
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2901020220	MI

General Provider Information

NPI Number	:	1689833469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROCK CHARLES MCKINLEY

Provider Business Mailing Address
First Line	:	3950 S ROCHESTER RD STE 2500
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5188
Country	:	US
Telephone Number	:	248-829-3635
Fax Number	:	248-829-3634

Provider Business Practice Location Address
First Line	:	3950 S ROCHESTER RD STE 2500
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5188
Country	:	US
Telephone Number	:	248-829-3635
Fax Number	:	248-829-3634

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

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	02/12/2019

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