Provider Demographics
NPI:1407340524
Name:THEIS, FALLON MADELINE (DDS)
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:MADELINE
Last Name:THEIS
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 1:1120 S GRADE CT SW
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-6739
Mailing Address - Country:US
Mailing Address - Phone:320-310-8325
Mailing Address - Fax:
Practice Address - Street 1:623 S SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-3339
Practice Address - Country:US
Practice Address - Phone:320-693-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist