Provider Demographics
NPI:1730943895
Name:BROCK, LINDSAY JANE (RDH, BS, OMT)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:JANE
Last Name:BROCK
Suffix:
Gender:F
Credentials:RDH, BS, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 PALMETTO GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-8304
Mailing Address - Country:US
Mailing Address - Phone:724-840-3338
Mailing Address - Fax:
Practice Address - Street 1:304 PALMETTO GLEN DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-8304
Practice Address - Country:US
Practice Address - Phone:724-840-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101616124Q00000X
PADH071269124Q00000X
SC10809124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist