Provider Demographics
NPI:1346201183
Name:DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Entity Type:Organization
Organization Name:DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Other - Org Name:MT STATE ORAL & MAXILLOFACIAL SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-720-7819
Mailing Address - Street 1:103 STATION PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8747
Mailing Address - Country:US
Mailing Address - Phone:304-720-7819
Mailing Address - Fax:304-345-5080
Practice Address - Street 1:1215 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-345-1092
Practice Address - Fax:304-345-5080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000817140OtherMT. STATE BCBS
WV4500012000Medicaid
WV4500012000Medicaid