Provider Demographics
NPI:1386647030
Name:WARD, BROCK R (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:R
Last Name:WARD
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 1:330 W SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:OWENTON
Mailing Address - State:KY
Mailing Address - Zip Code:40359-1533
Mailing Address - Country:US
Mailing Address - Phone:502-484-0091
Mailing Address - Fax:502-484-0091
Practice Address - Street 1:330 W SEMINARY ST
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359-1533
Practice Address - Country:US
Practice Address - Phone:502-484-0091
Practice Address - Fax:502-484-0091
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-09
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
KY78421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001690Medicaid