Provider Demographics
NPI:1356501365
Name:BOCK, DEREK JAMES (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JAMES
Last Name:BOCK
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:840 S WAUKEGAN RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2608
Mailing Address - Country:US
Mailing Address - Phone:847-615-5437
Mailing Address - Fax:847-615-2955
Practice Address - Street 1:840 S WAUKEGAN RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2608
Practice Address - Country:US
Practice Address - Phone:847-615-5437
Practice Address - Fax:847-615-2955
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210022191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics