Provider Demographics
NPI:1194997627
Name:HABLITZEL, MICHAEL DERRILL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DERRILL
Last Name:HABLITZEL
Suffix:
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 1:304 1/2 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1921
Mailing Address - Country:US
Mailing Address - Phone:419-734-2175
Mailing Address - Fax:
Practice Address - Street 1:304 1/2 MADISON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1921
Practice Address - Country:US
Practice Address - Phone:419-734-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH157561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0712732Medicaid