Provider Demographics
NPI:1982714994
Name:HAVRILAK, SAMUEL CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:CHARLES
Last Name:HAVRILAK
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 1:2419 E JOPPA RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234
Mailing Address - Country:US
Mailing Address - Phone:410-668-5035
Mailing Address - Fax:410-668-5036
Practice Address - Street 1:2419 E JOPPA RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234
Practice Address - Country:US
Practice Address - Phone:410-668-5035
Practice Address - Fax:410-668-5036
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD61461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3154OtherMARYLAND DENTAL PLAN