Provider Demographics
NPI:1366444085
Name:MUCHITENI, THEODORE GABRIEL (DMD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:GABRIEL
Last Name:MUCHITENI
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 1:2300 HEMBY LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3775
Mailing Address - Country:US
Mailing Address - Phone:252-830-0201
Mailing Address - Fax:252-830-2052
Practice Address - Street 1:2300 HEMBY LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3775
Practice Address - Country:US
Practice Address - Phone:252-830-0201
Practice Address - Fax:252-830-2052
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC69278OtherBLUE CROSS BLUE SHIELD OF
523612OtherUNITED CONCORDIA
NC6996278Medicaid
208734OtherTRIGON BCBS
NC69278OtherBLUE CROSS BLUE SHIELD OF
NC6996278Medicaid