Provider Demographics
NPI:1972631489
Name:HAVELKA, GREGORY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:HAVELKA
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 1:2410 S 73RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2395
Mailing Address - Country:US
Mailing Address - Phone:402-393-8439
Mailing Address - Fax:402-393-8593
Practice Address - Street 1:2410 S 73RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2395
Practice Address - Country:US
Practice Address - Phone:402-393-8439
Practice Address - Fax:402-393-8593
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE596782OtherUNITED CONCORDIA ID
NE4684OtherBLUE CROSS BLUE SHIELD ID