Provider Demographics
NPI:1366413528
Name:CROCK, BRIAN E (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:CROCK
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 1:175 MCMILLEN DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1810
Mailing Address - Country:US
Mailing Address - Phone:740-344-3372
Mailing Address - Fax:740-344-2552
Practice Address - Street 1:175 MCMILLEN DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1810
Practice Address - Country:US
Practice Address - Phone:740-344-3372
Practice Address - Fax:740-344-2552
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0970436Medicaid