Healthcare Provider Details

I. General information

NPI: 1073205258
Provider Name (Legal Business Name): THEODORE D NOVAK III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 OLD ELKHART RD STE 110
PALESTINE TX
75801-6047
US

IV. Provider business mailing address

5800 N INTERSTATE 35 STE 205
DENTON TX
76207-1438
US

V. Phone/Fax

Practice location:
  • Phone: 903-723-4669
  • Fax:
Mailing address:
  • Phone: 940-220-7833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41113
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number110457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: