Provider Demographics
NPI:1326199613
Name:DEVINE, THERESA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:DEVINE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 REED RD
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3655
Mailing Address - Country:US
Mailing Address - Phone:610-353-7811
Mailing Address - Fax:610-353-3565
Practice Address - Street 1:580 REED RD
Practice Address - Street 2:SUITE 7A
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3655
Practice Address - Country:US
Practice Address - Phone:610-353-7811
Practice Address - Fax:610-353-3565
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028181L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist