Provider Demographics
NPI:1356772677
Name:DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Entity type:Organization
Organization Name:DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-720-7819
Mailing Address - Street 1:103 STATION PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8747
Mailing Address - Country:US
Mailing Address - Phone:304-720-7819
Mailing Address - Fax:304-345-5080
Practice Address - Street 1:417 GRAND PARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26105
Practice Address - Country:US
Practice Address - Phone:304-699-5010
Practice Address - Fax:304-553-7268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty