Provider Demographics
NPI:1346493582
Name:THEODORE F MAYERDDS PA
Entity Type:Organization
Organization Name:THEODORE F MAYERDDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:800-409-2563
Mailing Address - Street 1:1904 W PARKSIDE LN
Mailing Address - Street 2:201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1228
Mailing Address - Country:US
Mailing Address - Phone:800-409-2563
Mailing Address - Fax:623-321-6268
Practice Address - Street 1:8100 HARPS MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3722
Practice Address - Country:US
Practice Address - Phone:800-409-2563
Practice Address - Fax:623-321-6268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC54501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty