Provider Demographics
NPI:1114009057
Name:HAYDUK, MICHAEL J (DDS MS D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HAYDUK
Suffix:
Gender:M
Credentials:DDS MS D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 ST JOHN ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7347
Mailing Address - Country:US
Mailing Address - Phone:219-872-3232
Mailing Address - Fax:219-872-3583
Practice Address - Street 1:450 ST JOHN ROAD
Practice Address - Street 2:SUITE 350
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7347
Practice Address - Country:US
Practice Address - Phone:219-872-3232
Practice Address - Fax:219-872-3583
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120085301223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics