Healthcare Provider Details

I. General information

NPI: 1609442540
Provider Name (Legal Business Name): ALLISON BOCKRATH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 E STATE ROUTE 73
WAYNESVILLE OH
45068-8812
US

IV. Provider business mailing address

3811 GRAND OAK TRL
DAYTON OH
45440-5011
US

V. Phone/Fax

Practice location:
  • Phone: 513-897-0248
  • Fax:
Mailing address:
  • Phone: 937-776-5019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10586
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.026442
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: