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General NPI Number Information
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NPI Number | 1750451225
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Entity Type | Individual
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Provider Name | WAYNE ALVIS ROCKEFELLER SR. DOCTOR OF DENTAL SUR
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Gender | Male
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 01/12/2012
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Provider Practice Location Address
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Address Line | 18591 W 10 MILE RD SUITE 4
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City | SOUTHFIELD
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State | MI
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Zip | 48075
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Country | US
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Telephone | 248-569-5260
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Fax | 248-569-6219
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Provider Business Mailing Address
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Address Line | 9541 JOSEPH CAMPAU
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City | HAMTRAMCK
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State | MI
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Zip | 48212
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Country | US
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Telephone | 313-972-4700
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Fax | 248-569-6219
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 14823
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License Number State | MI
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