Provider Demographics
NPI:1740454230
Name:JOHN L. HAVLICK, D.D.S.
Entity type:Organization
Organization Name:JOHN L. HAVLICK, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRITCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-462-0780
Mailing Address - Street 1:1302 VALE PARK RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2722
Mailing Address - Country:US
Mailing Address - Phone:219-462-0780
Mailing Address - Fax:219-464-0229
Practice Address - Street 1:1302 VALE PARK RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2722
Practice Address - Country:US
Practice Address - Phone:219-462-0780
Practice Address - Fax:219-464-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007779A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty