Provider Demographics
NPI:1124001854
Name:ROCHA, THEODORE EVERETT (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:EVERETT
Last Name:ROCHA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG. H 2005 KNIGHT LANE
Mailing Address - Street 2:NAVY MEDICINE SUPPORT COMM ATTN: MEDICAL STAFF SERVICES
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:904-542-7200
Mailing Address - Fax:
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:NAVAL HOSPITAL BEAUFORT, ATTN:PROF AFFAIRS COORDINATOR
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-3500
Practice Address - Fax:843-228-5196
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26281122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN