Provider Demographics
NPI:1790239010
Name:ANTHONY R BROCK DMD PLLC
Entity Type:Organization
Organization Name:ANTHONY R BROCK DMD PLLC
Other - Org Name:STETSON VILLAGE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-533-4895
Mailing Address - Street 1:3870 W HAPPY VALLEY RD
Mailing Address - Street 2:SUITE #154
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3295
Mailing Address - Country:US
Mailing Address - Phone:623-533-4895
Mailing Address - Fax:623-533-6246
Practice Address - Street 1:3870 W HAPPY VALLEY RD
Practice Address - Street 2:SUITE #154
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3295
Practice Address - Country:US
Practice Address - Phone:623-533-4895
Practice Address - Fax:623-533-6246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ88851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1083976732OtherNPI#