Provider Demographics
NPI:1801003074
Name:BROCK, JUSTIN (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:23922 CINCO VILLAGE CENTER BLVD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-6619
Mailing Address - Country:US
Mailing Address - Phone:281-392-1130
Mailing Address - Fax:281-392-1643
Practice Address - Street 1:23922 CINCO VILLAGE CENTER BLVD
Practice Address - Street 2:SUITE 111
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-6619
Practice Address - Country:US
Practice Address - Phone:281-392-1130
Practice Address - Fax:281-392-1643
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery