Provider Demographics
NPI:1801505607
Name:DESOTO, BROCK J (DDS)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:J
Last Name:DESOTO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 CORTADERIA ST NE APT 4028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8012
Mailing Address - Country:US
Mailing Address - Phone:505-269-1818
Mailing Address - Fax:
Practice Address - Street 1:5925 WYOMING BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3841
Practice Address - Country:US
Practice Address - Phone:505-269-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD56971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice