Provider Demographics
NPI:1386392629
Name:BROCK, JEREMY DUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DUSTIN
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 1:10868 US 15 501 HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10868 US HIGHWAY 15 501
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5149
Practice Address - Country:US
Practice Address - Phone:910-585-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12842122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program