Provider Demographics
NPI:1063639805
Name:NOCK, DAVID L (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:NOCK
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 1:425 PATTERSON RD STE 501
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1910
Mailing Address - Country:US
Mailing Address - Phone:970-242-4433
Mailing Address - Fax:
Practice Address - Street 1:425 PATTERSON RD STE 501
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1910
Practice Address - Country:US
Practice Address - Phone:970-242-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1059551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02059558Medicaid
CO105955OtherSTATE LICENSE NUMBER