Provider Demographics
NPI:1124238753
Name:OPALKA, THEODORE F JR (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:F
Last Name:OPALKA
Suffix:JR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 COUNTRY CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4615
Mailing Address - Country:US
Mailing Address - Phone:330-856-2831
Mailing Address - Fax:
Practice Address - Street 1:217 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1939
Practice Address - Country:US
Practice Address - Phone:330-856-6807
Practice Address - Fax:330-856-9970
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0558007Medicaid