Provider Demographics
NPI:1447596655
Name:BROCK, KALLIE LAW (DMD)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:LAW
Last Name:BROCK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:LYNN
Other - Last Name:LAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:205 WALESKA RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2493
Mailing Address - Country:US
Mailing Address - Phone:770-479-3713
Mailing Address - Fax:
Practice Address - Street 1:205 WALESKA RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2493
Practice Address - Country:US
Practice Address - Phone:770-479-3713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2015-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC81621223G0001X
GADN014538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist