Provider Demographics
NPI:1043408792
Name:ROCKEFELLER, VAN PELT (DMD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:PELT
Last Name:ROCKEFELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2885 STONECREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:317-529-4047
Mailing Address - Fax:
Practice Address - Street 1:1178 GRIMES BRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3935
Practice Address - Country:US
Practice Address - Phone:770-992-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT9110225100000X
390200000X
GADN015157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I650028Medicare PIN
GA511I650031Medicare PIN
GAGRP4895Medicare PIN