Provider Demographics
NPI:1407258619
Name:THEODORE, MIRLINE (RDH)
Entity Type:Individual
Prefix:
First Name:MIRLINE
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 TOWN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2323
Mailing Address - Country:US
Mailing Address - Phone:860-892-7042
Mailing Address - Fax:
Practice Address - Street 1:47 TOWN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2323
Practice Address - Country:US
Practice Address - Phone:860-892-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8293124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist