Provider Demographics
NPI:1073205258
Name:NOVAK, THEODORE D III (DDS)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:D
Last Name:NOVAK
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 N INTERSTATE 35 STE 205
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-1438
Mailing Address - Country:US
Mailing Address - Phone:940-220-7833
Mailing Address - Fax:
Practice Address - Street 1:419 OLD ELKHART RD STE 110
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6047
Practice Address - Country:US
Practice Address - Phone:903-723-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41113122300000X
CA110457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist