NPIMap

Organization Active NPI

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

Doing business as Mt State Oral & Facial Surgery

  • Oral and Maxillofacial Surgery (Dentist)
  • Charleston, WV
National Provider Identifier
1447711858
Registry record updated May 30, 2025
On this page

Key facts

NPPES NPI Registry
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 & Facial Surgery
Practice address
4307 Maccorkle Ave SE
Charleston, WV 25304-2500
Phone
(304) 345-1092
NPI assigned
Mar 28, 2019
Last updated
May 30, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 30, 2025

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) 345-1092

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist) 1223S0112X NU Primary

Addresses

Primary practice location

4307 Maccorkle Ave SE
Charleston, WV 25304-2500

Mailing address

103 Station Place Way
Hurricane, WV 25526-8747
Phone (304) 720-7819

Other names 1

  • Mt State Oral & Facial Surgery Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
51D2169104DRS Brock Henderson, Diprisco, Ravelo & Green4307 Maccorkle Ave SE, Charleston, WV 25304Certificate of waiverJul 15, 2027

National Provider Directory

National Provider Directory

Locations

4307 Maccorkle Ave SE
Charleston, WV 25304
Phone (304) 205-6123

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1553731200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748563200000",
    "number": "1447711858",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4307 MACCORKLE AVE SE",
            "city": "CHARLESTON",
            "state": "WV",
            "postal_code": "253042500",
            "telephone_number": "304-345-1092"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-28",
        "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": "304-345-1092"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mt State Oral & Facial Surgery",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mt State Oral & Facial Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charleston, WV

Sources for this page

  • 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.