Provider Demographics
NPI:1306864442
Name:HAVLICK, JOHN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:HAVLICK
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 1:1302 VALE PARK RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2722
Mailing Address - Country:US
Mailing Address - Phone:219-462-0780
Mailing Address - Fax:219-464-0229
Practice Address - Street 1:1302 VALE PARK RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2722
Practice Address - Country:US
Practice Address - Phone:219-462-0780
Practice Address - Fax:219-464-0229
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007779A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice