Provider Demographics
NPI:1750451225
Name:ROCKEFELLER, WAYNE ALVIS SR (DOCTOR OF DENTAL SUR)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALVIS
Last Name:ROCKEFELLER
Suffix:SR
Gender:M
Credentials:DOCTOR OF DENTAL SUR
Other - Prefix:
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Mailing Address - Street 1:9541 JOSEPH CAMPAU
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212
Mailing Address - Country:US
Mailing Address - Phone:313-972-4700
Mailing Address - Fax:248-569-6219
Practice Address - Street 1:18591 W 10 MILE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-569-5260
Practice Address - Fax:248-569-6219
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-01-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI148231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice