Provider Demographics
NPI:1992910244
Name:SCHROCK, KURT R I
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:R
Last Name:SCHROCK
Suffix:I
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:ALICE
Other - Middle Name:MEGAN
Other - Last Name:SCHROCK
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:DDS,PA
Mailing Address - Street 1:1903 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3711
Mailing Address - Country:US
Mailing Address - Phone:601-638-6011
Mailing Address - Fax:601-638-6140
Practice Address - Street 1:1903 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-638-6011
Practice Address - Fax:601-638-6140
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1651-741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice