Provider Demographics
NPI:1497964555
Name:PELOK, DAVID RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:PELOK
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 1:750 E LINFOOT ST
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1813
Mailing Address - Country:US
Mailing Address - Phone:419-335-8466
Mailing Address - Fax:419-335-0700
Practice Address - Street 1:229 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1265
Practice Address - Country:US
Practice Address - Phone:419-337-2391
Practice Address - Fax:419-335-0700
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0127351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0049021Medicaid
OH06135Medicaid
OH9182582Medicaid