Provider Demographics
NPI:1114013604
Name:BROWN, THEODORE A (DDS)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:BROWN
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:P.O. BOX 188
Mailing Address - Street 2:
Mailing Address - City:MOHALL
Mailing Address - State:ND
Mailing Address - Zip Code:58761-0188
Mailing Address - Country:US
Mailing Address - Phone:701-756-6655
Mailing Address - Fax:
Practice Address - Street 1:106 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:MOHALL
Practice Address - State:ND
Practice Address - Zip Code:58761
Practice Address - Country:US
Practice Address - Phone:701-756-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41000Medicaid
ND901760OtherDENTAL SERVICE CORPORATIO
ND879031OtherUNITED CONCORDIA