Provider Demographics
NPI:1205939196
Name:MARK A . & MICHAEL D. HABLITZEL, D.D.S., INC.
Entity type:Organization
Organization Name:MARK A . & MICHAEL D. HABLITZEL, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HABLITZEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-734-2175
Mailing Address - Street 1:304 1/2 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1921
Mailing Address - Country:US
Mailing Address - Phone:419-734-2175
Mailing Address - Fax:
Practice Address - Street 1:304 1/2 MADISON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1921
Practice Address - Country:US
Practice Address - Phone:419-734-2175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0138851223G0001X
OH157561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0392061Medicaid