Provider Demographics
NPI:1689833469
Name:MCKINLEY, BROCK CHARLES
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:CHARLES
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 S ROCHESTER RD STE 2500
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5188
Mailing Address - Country:US
Mailing Address - Phone:248-829-3635
Mailing Address - Fax:248-829-3634
Practice Address - Street 1:3950 S ROCHESTER RD STE 2500
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5188
Practice Address - Country:US
Practice Address - Phone:248-829-3635
Practice Address - Fax:248-829-3634
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9658122300000X
MI29010202201223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist