Provider Demographics
NPI:1336211614
Name:BROCKMAN, ERIC SCOTT (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SCOTT
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MEADOWBROOK DR APT 635
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-6913
Mailing Address - Country:US
Mailing Address - Phone:206-498-0877
Mailing Address - Fax:
Practice Address - Street 1:7601 CASTOR AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-4027
Practice Address - Country:US
Practice Address - Phone:215-722-4290
Practice Address - Fax:215-722-3734
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000078251223P0300X
WI1001067-151223P0300X
TN118761223P0300X
PADS028499L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics