Organization
DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC
Active
Other names
Mt. State Oral & Maxillofacial Surgeons
Organization subpart
No
Provider details
NPI number
Authorized official
LESLEY MARIE COYNER (CREDENTIALING)
(304) 720-7819
Entity
Organization
Contact information
Practice address
100A PRESTIGE PARK DR, HURRICANE, WV 25526
(304) 757-0272
(304) 757-0273
Mailing address
103 STATION PLACE WAY, HURRICANE, WV 25526-8747
(304) 345-1092
(304) 345-5080
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000817140
MT. STATE BCBS
WV
05
—
4500012000
—
WA
01
—
9305402
MEDICARE PTAN
WV
Enumeration date
03/31/2006
Last updated
05/29/2025
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