Provider Demographics
NPI:1487948857
Name:PAVLAK, JASON THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:THOMAS
Last Name:PAVLAK
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 1:725 PHEASANT RUN WEST DR
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-4544
Mailing Address - Country:US
Mailing Address - Phone:248-624-1447
Mailing Address - Fax:
Practice Address - Street 1:725 N MILFORD RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1536
Practice Address - Country:US
Practice Address - Phone:248-685-8748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010203991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice