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

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

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

## Provider details

- **NPI number:** 1447711858
- **Authorized official:** LESLEY MARIE COYNER (CREDENTIALING)
- **Authorized official phone:** (304) 345-1092

## Contact information

- **Practice address:** 4307 MACCORKLE AVE SE, CHARLESTON, WV 25304-2500
- **Practice address phone:** (304) 345-1092
- **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:** 03/28/2019
- **Last updated:** 05/30/2025