Healthcare Provider Details

I. General information

NPI: 1194822908
Provider Name (Legal Business Name): JOHN SECREST PYKE III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33399 WALKER RD SUITE D
AVON LAKE OH
44012
US

IV. Provider business mailing address

33399 WALKER RD SUITE D
AVON LAKE OH
44012
US

V. Phone/Fax

Practice location:
  • Phone: 440-933-2549
  • Fax: 440-933-3574
Mailing address:
  • Phone: 440-933-2549
  • Fax: 440-933-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30021033
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: