Provider Demographics
NPI:1649454331
Name:PAWLAK, ELIZABETH WALLIN (DMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WALLIN
Last Name:PAWLAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 DEMAREE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-4622
Mailing Address - Country:US
Mailing Address - Phone:812-273-8744
Mailing Address - Fax:
Practice Address - Street 1:160 DEMAREE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4622
Practice Address - Country:US
Practice Address - Phone:812-273-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist