Provider Demographics
NPI:1457416299
Name:BLOCHER, BRIAN J (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:BLOCHER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MAYFAIR RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-607-0222
Mailing Address - Fax:414-607-0220
Practice Address - Street 1:201 N MAYFAIR RD
Practice Address - Street 2:SUITE 520
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-607-0222
Practice Address - Fax:414-607-0220
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4002204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33683900Medicaid
WIU35770Medicare UPIN
WIU35770Medicare ID - Type Unspecified