Provider Demographics
NPI:1114935632
Name:RENKE, PAUL A (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:RENKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:STE 10
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309
Mailing Address - Country:US
Mailing Address - Phone:248-651-4202
Mailing Address - Fax:248-651-4204
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:STE 10
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309
Practice Address - Country:US
Practice Address - Phone:248-651-4202
Practice Address - Fax:248-651-4204
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016821204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N18960Medicare ID - Type Unspecified
U82209Medicare UPIN