DRS Brock, Henderson, Di Prisco, Ravelo and Green Inc

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

Legal business name

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

Doing business as

Mt State Oral & Maxillofacial Surge

Practice address

417 Grand Park Dr
Suite 103
Parkersburg, WV 26105

Phone

(304) 699-5010

Fax

(304) 553-7268

NPI assigned

Dec 12, 2013

Last updated

May 30, 2025By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lesley Marie Coyner

Title

Credentialing

Phone

(304) 720-7819

Specialties & licenses 1

Addresses

Other names 1

• Mt State Oral & Maxillofacial Surge Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1386806400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748563200000",
    "number": "1356772677",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 STATION PLACE WAY",
            "city": "HURRICANE",
            "state": "WV",
            "postal_code": "255268747",
            "telephone_number": "304-720-7819",
            "fax_number": "304-345-5080"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "417 GRAND PARK DR",
            "address_2": "SUITE 103",
            "city": "PARKERSBURG",
            "state": "WV",
            "postal_code": "26105",
            "telephone_number": "304-699-5010",
            "fax_number": "304-553-7268"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-12",
        "last_updated": "2025-05-30",
        "certification_date": "2025-05-30",
        "status": "A",
        "authorized_official_last_name": "COYNER",
        "authorized_official_first_name": "LESLEY",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "304-720-7819"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "WV",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mt State Oral & Maxillofacial Surge",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mt State Oral & Maxillofacial Surge",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Oral and Maxillofacial Surgery (Dentist) in Parkersburg, WV
• Providers in Parkersburg, WV by specialty
• Oral and Maxillofacial Surgery (Dentist) in West Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 30, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.