Provider Demographics
NPI:1669757159
Name:CASPERSON, BROCK WILDE (DMD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:WILDE
Last Name:CASPERSON
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 1:929 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4865
Mailing Address - Country:US
Mailing Address - Phone:435-656-5900
Mailing Address - Fax:
Practice Address - Street 1:929 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4865
Practice Address - Country:US
Practice Address - Phone:435-656-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8345061-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice