Provider Demographics
NPI:1114022795
Name:HEALY, THEODORE MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MARK
Last Name:HEALY
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 1:37956 RHONSWOOD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9752
Mailing Address - Country:US
Mailing Address - Phone:248-474-0937
Mailing Address - Fax:
Practice Address - Street 1:1359 CHAMPAIGN
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3303
Practice Address - Country:US
Practice Address - Phone:313-386-9660
Practice Address - Fax:313-386-5515
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI93531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice