Provider Demographics
NPI:1184930653
Name:BROCK, ADAM WILEY (DMD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:WILEY
Last Name:BROCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BEEMAN PL
Mailing Address - Street 2:
Mailing Address - City:FT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7009
Mailing Address - Country:US
Mailing Address - Phone:785-239-4261
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT GREGG ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS03828201223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics