Provider Demographics
NPI:1124172838
Name:PAWLICK, VIVIANA VAGALAU (DDS)
Entity type:Individual
Prefix:MRS
First Name:VIVIANA
Middle Name:VAGALAU
Last Name:PAWLICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VIVIANA
Other - Middle Name:DINA
Other - Last Name:VAGALAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8998 GAUNT RD
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-8646
Mailing Address - Country:US
Mailing Address - Phone:231-536-9606
Mailing Address - Fax:
Practice Address - Street 1:220 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1631
Practice Address - Country:US
Practice Address - Phone:231-547-6523
Practice Address - Fax:231-547-6238
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4800808Medicaid