Provider Demographics
NPI:1346500121
Name:BROCK, JASON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
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 1:14740 BARRYKNOLL LN
Mailing Address - Street 2:120
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-2884
Mailing Address - Country:US
Mailing Address - Phone:281-584-0550
Mailing Address - Fax:281-584-0589
Practice Address - Street 1:14740 BARRYKNOLL LN
Practice Address - Street 2:120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-2884
Practice Address - Country:US
Practice Address - Phone:281-584-0550
Practice Address - Fax:281-584-0589
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284651223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program