Provider Demographics
NPI:1144492067
Name:PICKETT, WAYNE ERIC (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ERIC
Last Name:PICKETT
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 1:5574 COOLEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-3015
Mailing Address - Country:US
Mailing Address - Phone:248-682-2300
Mailing Address - Fax:248-682-9313
Practice Address - Street 1:5574 COOLEY LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-3015
Practice Address - Country:US
Practice Address - Phone:248-682-2300
Practice Address - Fax:248-682-9313
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010160461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice