Provider Demographics
NPI:1952423840
Name:AVILA, JOHN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:AVILA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2344 CYNTHIA DR
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9361
Mailing Address - Country:US
Mailing Address - Phone:219-477-6082
Mailing Address - Fax:219-879-2915
Practice Address - Street 1:400 TEEGARDEN ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3175
Practice Address - Country:US
Practice Address - Phone:219-326-0043
Practice Address - Fax:219-326-8909
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100375060Medicaid