Provider Demographics
NPI:1336795897
Name:MARK D. DEBOCK DDS
Entity Type:Organization
Organization Name:MARK D. DEBOCK DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEBOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-238-0248
Mailing Address - Street 1:7500 4TH AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3209
Mailing Address - Country:US
Mailing Address - Phone:718-238-0248
Mailing Address - Fax:630-614-4627
Practice Address - Street 1:7500 4TH AVE STE A1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3209
Practice Address - Country:US
Practice Address - Phone:718-238-0248
Practice Address - Fax:630-614-4627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01045312Medicaid