Provider Demographics
NPI:1376555227
Name:BROCK, JOHN E (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:BROCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Practice Address - Street 1:100A PRESTIGE PARK DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8417
Practice Address - Country:US
Practice Address - Phone:304-757-0272
Practice Address - Fax:304-757-0273
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV129OtherSPECIALIST, ORAL AND MAXILLOFACIAL SURGERY
WV3308OtherWV DENTAL LIC.
WV3810012787Medicaid
KY10439OtherKY DENTAL LICENSE