=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205939196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK A . & MICHAEL D. HABLITZEL, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 03/25/2008
-----------------------------------------------------
=====================================================
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 | DENTIST
-----------------------------------------------------
Name | DR. MICHAEL D HABLITZEL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 419-734-2175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 013885
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 15756
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------