NPIMap

Organization Active NPI

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

  • Oral and Maxillofacial Surgery (Dentist)
  • Hurricane, WV
National Provider Identifier
1992766737
Registry record updated May 29, 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
Practice address
100A Prestige Park Dr
Hurricane, WV 25526
Phone
(304) 757-0272
Fax
(304) 757-0273
NPI assigned
Mar 31, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 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) 720-7819

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X Primary

Addresses

Primary practice location

100A Prestige Park Dr
Hurricane, WV 25526

Mailing address

103 Station Place Way
Hurricane, WV 25526-8747
Phone (304) 345-1092

Other identifiers 3

IdentifierTypeStateIssuer
4500012000MedicaidWA
9305402OtherWVMEDICARE PTAN
000817140OtherWVMT. STATE BCBS

Other names 1

  • Mt. State Oral & Maxillofacial Surgeons Other name

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1143763200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748476800000",
    "number": "1992766737",
    "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": "304-345-1092",
            "fax_number": "304-345-5080"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100A PRESTIGE PARK DR",
            "city": "HURRICANE",
            "state": "WV",
            "postal_code": "25526",
            "telephone_number": "304-757-0272",
            "fax_number": "304-757-0273"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DRS BROCK, HENDERSON, DI PRISCO, RAVELO AND GREEN INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-31",
        "last_updated": "2025-05-29",
        "certification_date": "2025-05-29",
        "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": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4500012000",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "9305402",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MT. STATE BCBS",
            "identifier": "000817140",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mt. State Oral & Maxillofacial Surgeons",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Mt. State Oral & Maxillofacial Surgeons",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Hurricane, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.