Provider Demographics
NPI:1659711125
Name:FLORES, BROC A (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROC
Middle Name:A
Last Name:FLORES
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 1:500 PRESERVE AVE E APT 5101
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-1692
Mailing Address - Country:US
Mailing Address - Phone:610-585-9989
Mailing Address - Fax:
Practice Address - Street 1:MCRD PARRIS ISLAND
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:29905
Practice Address - Country:US
Practice Address - Phone:843-228-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62509122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist