MEDICARE: DR. ROBERT JASON PAVELKA D.D.S., M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	19346	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	L8883	TX

General Provider Information

NPI Number	:	1700845930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT JASON PAVELKA D.D.S., M.D.

Provider Business Mailing Address
First Line	:	400 S COTTONWOOD DR
Second Line	:	SUITE B
City	:	RICHARDSON
State	:	TX
Zip	:	75080-5708
Country	:	US
Telephone Number	:	972-231-6661
Fax Number	:	972-231-3161

Provider Business Practice Location Address
First Line	:	400 S COTTONWOOD DR
Second Line	:	SUITE B
City	:	RICHARDSON
State	:	TX
Zip	:	75080-5708
Country	:	US
Telephone Number	:	972-231-6661
Fax Number	:	972-231-3161

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	07/13/2007

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