Provider Demographics
NPI:1215598099
Name:CAMERON, BROCK ALEXANDER (DMD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:ALEXANDER
Last Name:CAMERON
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 1:2424 S 9TH ST APT 231
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-4731
Mailing Address - Country:US
Mailing Address - Phone:618-977-4595
Mailing Address - Fax:
Practice Address - Street 1:3115 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-1602
Practice Address - Country:US
Practice Address - Phone:314-451-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190227161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice