Provider Demographics
NPI:1669415980
Name:ROCKWELL, PAUL BERTRON (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:BERTRON
Last Name:ROCKWELL
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 1:3351 CLAYSTONE SE
Mailing Address - Street 2:SUITE G 17
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-949-9060
Mailing Address - Fax:616-949-5680
Practice Address - Street 1:3351 CLAYSTONE SE
Practice Address - Street 2:SUITE G 17
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-949-9060
Practice Address - Fax:616-949-5680
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901008614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ086140OtherBLUE CROSS BS