Provider Demographics
NPI:1003916826
Name:SCHROCK, BENJAMIN LEON (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LEON
Last Name:SCHROCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2109
Mailing Address - Country:US
Mailing Address - Phone:601-529-2131
Mailing Address - Fax:
Practice Address - Street 1:1721 MEDICAL PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2109
Practice Address - Country:US
Practice Address - Phone:228-267-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1505631223G0001X
AL1061223G0001X
MS3405-061223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC60115BMedicare UPIN