Provider Demographics
NPI:1497925903
Name:BROCK, JIMMY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:L
Last Name:BROCK
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 1:429 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-1405
Mailing Address - Country:US
Mailing Address - Phone:770-258-5516
Mailing Address - Fax:770-258-5517
Practice Address - Street 1:429 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BOWDON
Practice Address - State:GA
Practice Address - Zip Code:30108-1405
Practice Address - Country:US
Practice Address - Phone:770-258-5516
Practice Address - Fax:770-258-5517
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist