Provider Demographics
NPI:1629193743
Name:GAVLAK, JOLENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOLENE
Middle Name:
Last Name:GAVLAK
Suffix:
Gender:F
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:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866-0060
Mailing Address - Country:US
Mailing Address - Phone:814-342-1101
Mailing Address - Fax:
Practice Address - Street 1:109 N CENTRE ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-1661
Practice Address - Country:US
Practice Address - Phone:814-342-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031452L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA050047OtherUNITED CONCORDIA
PA0018194120003Medicaid