Provider Demographics
NPI:1184911745
Name:MYRON D. SCHROCK, D.M.D., P.A.
Entity type:Organization
Organization Name:MYRON D. SCHROCK, D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SCHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-237-1400
Mailing Address - Street 1:17470 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1772
Mailing Address - Country:US
Mailing Address - Phone:850-237-1400
Mailing Address - Fax:
Practice Address - Street 1:17470 MAIN ST N
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1772
Practice Address - Country:US
Practice Address - Phone:850-237-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00135271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074702500Medicaid