Provider Demographics
NPI:1699798470
Name:FLACK, JOHN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:FLACK
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 1:829 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1413
Mailing Address - Country:US
Mailing Address - Phone:419-225-0080
Mailing Address - Fax:
Practice Address - Street 1:829 E ELM ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1413
Practice Address - Country:US
Practice Address - Phone:419-225-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH149391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice