Basic Information
Provider Information
NPI: 1417486689
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HALL
FirstName: BROCK
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7400 W ARROWHEAD CLUBHOUSE DR APT 2063
Address2:  
City: GLENDALE
State: AZ
PostalCode: 853088827
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2708 W NOLANA AVE STE 120
Address2:  
City: MCALLEN
State: TX
PostalCode: 785044181
CountryCode: US
TelephoneNumber: 9566822209
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/09/2017
LastUpdateDate: 06/09/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X33065TXY Dental ProvidersDentistGeneral Practice

No ID Information.


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