Provider Demographics
NPI:1033402557
Name:BROCK, STUART (DDS)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5459 W 85TH TER
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66207-1722
Mailing Address - Country:US
Mailing Address - Phone:913-642-8792
Mailing Address - Fax:
Practice Address - Street 1:5459 W 85TH TER
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66207-1722
Practice Address - Country:US
Practice Address - Phone:913-642-8792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist