Provider Demographics
NPI:1780253864
Name:FOCKEN, ALIVIA GRACE (DDS)
Entity type:Individual
Prefix:MRS
First Name:ALIVIA
Middle Name:GRACE
Last Name:FOCKEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 PONY EXPRESS RD
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-2565
Mailing Address - Country:US
Mailing Address - Phone:308-440-1540
Mailing Address - Fax:
Practice Address - Street 1:2714 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-4437
Practice Address - Country:US
Practice Address - Phone:308-455-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7734122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist