Provider Demographics
NPI:1407986482
Name:HARLESS, THEODORE ROBERT (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ROBERT
Last Name:HARLESS
Suffix:
Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:4760 AUSTELL RD STE 5
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-2007
Mailing Address - Country:US
Mailing Address - Phone:770-948-0300
Mailing Address - Fax:770-948-7588
Practice Address - Street 1:4760 AUSTELL RD STE 5
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-2007
Practice Address - Country:US
Practice Address - Phone:770-948-0300
Practice Address - Fax:770-948-7588
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0073141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics