Provider Demographics
NPI:1083800429
Name:MCWILLIE, THEODORE ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ALBERT
Last Name:MCWILLIE
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 1:4660 S EASTERN AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6137
Mailing Address - Country:US
Mailing Address - Phone:702-456-0005
Mailing Address - Fax:
Practice Address - Street 1:4660 S EASTERN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6137
Practice Address - Country:US
Practice Address - Phone:702-456-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV21031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice