Provider Demographics
NPI:1073639324
Name:BROCK, JOHNETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHNETTE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8737 COLESVILLE RD
Mailing Address - Street 2:#LL105
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3928
Mailing Address - Country:US
Mailing Address - Phone:301-588-3083
Mailing Address - Fax:304-588-3084
Practice Address - Street 1:8737 COLESVILLE RD
Practice Address - Street 2:#LL105
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3928
Practice Address - Country:US
Practice Address - Phone:301-588-3083
Practice Address - Fax:304-588-3084
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD011819200Medicaid