Provider Demographics
NPI:1063419182
Name:STROCK, PETER EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:EDWARD
Last Name:STROCK
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:PO BOX 1718
Mailing Address - Street 2:93 MAIN STREET
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0909
Mailing Address - Country:US
Mailing Address - Phone:508-693-1319
Mailing Address - Fax:508-693-4692
Practice Address - Street 1:93 MAIN ST
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5402
Practice Address - Country:US
Practice Address - Phone:508-693-1319
Practice Address - Fax:508-693-4692
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA99021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice