Provider Demographics
NPI:1154447415
Name:PAVELKA, MIRO A (DDS, MSD)
Entity Type:Individual
Prefix:
First Name:MIRO
Middle Name:A
Last Name:PAVELKA
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S COTTONWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5708
Mailing Address - Country:US
Mailing Address - Phone:972-231-6661
Mailing Address - Fax:972-231-3161
Practice Address - Street 1:400 S COTTONWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5708
Practice Address - Country:US
Practice Address - Phone:972-231-6661
Practice Address - Fax:972-231-3161
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD115211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15203Medicare UPIN
TXD11521Medicare ID - Type Unspecified