Provider Demographics
NPI:1679780993
Name:BROCK WESTOVER DDS, M.ED.P.C.
Entity Type:Organization
Organization Name:BROCK WESTOVER DDS, M.ED.P.C.
Other - Org Name:ELK AVENUE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:B
Authorized Official - Last Name:WESTOVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-214-6282
Mailing Address - Street 1:PO BOX 1228
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-1228
Mailing Address - Country:US
Mailing Address - Phone:970-349-5880
Mailing Address - Fax:970-349-9485
Practice Address - Street 1:412 ELK AVE.
Practice Address - Street 2:
Practice Address - City:CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81224-1228
Practice Address - Country:US
Practice Address - Phone:970-349-5880
Practice Address - Fax:970-349-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO85711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty