Provider Demographics
NPI:1073205258
Name:NOVAK, THEODORE D III
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:D
Last Name:NOVAK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 LANTERN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-5832
Mailing Address - Country:US
Mailing Address - Phone:916-769-2652
Mailing Address - Fax:
Practice Address - Street 1:714 TIVERTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8361
Practice Address - Country:US
Practice Address - Phone:310-206-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA024161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist