Provider Demographics
NPI:1740021013
Name:BROCK, AUSTIN MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:MICHAEL
Last Name:BROCK
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 1:8478 W MONONA LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-7418
Mailing Address - Country:US
Mailing Address - Phone:360-477-9288
Mailing Address - Fax:
Practice Address - Street 1:3870 W HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3295
Practice Address - Country:US
Practice Address - Phone:623-533-4895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0121581223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice