=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194997627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL DERRILL HABLITZEL D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2008
-----------------------------------------------------
Last Update Date | 03/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 1/2 MADISON ST
-----------------------------------------------------
City | PORT CLINTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43452-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-734-2175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 1/2 MADISON ST
-----------------------------------------------------
City | PORT CLINTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43452-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-734-2175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | OH15756
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------