Provider Demographics
NPI:1568796191
Name:PAVLICK, MATTHEW DAVID (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:PAVLICK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4441
Mailing Address - Country:US
Mailing Address - Phone:330-678-6564
Mailing Address - Fax:330-676-6973
Practice Address - Street 1:1551 S WATER ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4441
Practice Address - Country:US
Practice Address - Phone:330-678-6564
Practice Address - Fax:330-676-6973
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-097190204E00000X
OH30-0233851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery