Provider Demographics
NPI:1043227838
Name:CHICVAK, JOHN E (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:CHICVAK
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 1:1044 NORTHERN BLVD.
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576
Mailing Address - Country:US
Mailing Address - Phone:516-466-1177
Mailing Address - Fax:516-466-0763
Practice Address - Street 1:1044 NORTHERN BLVD.
Practice Address - Street 2:SUITE 306
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-466-1177
Practice Address - Fax:516-466-0763
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0428191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01244655Medicaid