# DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Mt State Oral & Facial Surgery
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003388117
- **Authorized official:** LESLEY MARIE COYNER (CREDENTIALING)
- **Authorized official phone:** (304) 345-1092

## Contact information

- **Practice address:** 2301 LEXINGTON AVE STE 120, ASHLAND, KY 41101-2807
- **Practice address phone:** (304) 399-1092
- **Mailing address:** 103 STATION PLACE WAY, HURRICANE, WV 25526-8747
- **Mailing address phone:** (304) 720-7819

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |

## Other

- **Enumeration date:** 12/31/2018
- **Last updated:** 05/29/2025