MEDICARE: DR. BROCK PHILIPS 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	1223G0001X	General Practice Dentistry	DN14354	FL

General Provider Information

NPI Number	:	1699094151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROCK PHILIPS DMD

Provider Business Mailing Address
First Line	:	4540 SOUTHSIDE BLVD
Second Line	:	SUITE 801
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5492
Country	:	US
Telephone Number	:	904-642-2010
Fax Number	:	904-642-8282

Provider Business Practice Location Address
First Line	:	4540 SOUTHSIDE BLVD
Second Line	:	SUITE 801
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5492
Country	:	US
Telephone Number	:	904-642-2010
Fax Number	:	904-642-8282

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

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	11/16/2011

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