Provider Demographics
NPI:1699088369
Name:BRIAN J. BLOCHER DDS SC
Entity type:Organization
Organization Name:BRIAN J. BLOCHER DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BLOCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS SC
Authorized Official - Phone:414-607-0222
Mailing Address - Street 1:201 N MAYFAIR RD STE 520
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4216
Mailing Address - Country:US
Mailing Address - Phone:414-607-0222
Mailing Address - Fax:414-607-0220
Practice Address - Street 1:201 N MAYFAIR RD STE 520
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-607-0222
Practice Address - Fax:414-607-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33683900Medicaid