Provider Demographics
NPI:1083796023
Name:THEROUX, TINA RENEE
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:RENEE
Last Name:THEROUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WORCESTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01536-1050
Mailing Address - Country:US
Mailing Address - Phone:508-839-2262
Mailing Address - Fax:508-839-6556
Practice Address - Street 1:103 WORCESTER ST STE A
Practice Address - Street 2:
Practice Address - City:NORTH GRAFTON
Practice Address - State:MA
Practice Address - Zip Code:01536-1050
Practice Address - Country:US
Practice Address - Phone:508-839-2262
Practice Address - Fax:508-839-6556
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice