Provider Demographics
NPI:1114975786
Name:CERCEK, JOHN D (DDS, MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:CERCEK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 DUSTIN RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-4341
Mailing Address - Country:US
Mailing Address - Phone:419-698-3782
Mailing Address - Fax:419-698-9560
Practice Address - Street 1:3140 DUSTIN RD
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4341
Practice Address - Country:US
Practice Address - Phone:419-698-3782
Practice Address - Fax:419-698-9560
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH302124211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0122594Medicaid