Provider Demographics
NPI:1720734684
Name:DRS KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Entity Type:Organization
Organization Name:DRS KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Other - Org Name:
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:
Practice Address - Street 1:895 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2105
Practice Address - Country:US
Practice Address - Phone:304-425-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DRS KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty