Provider Demographics
NPI:1417172156
Name:TITUS, THERESIA LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:LYNN
Last Name:TITUS
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 1:1905 MICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-9460
Mailing Address - Country:US
Mailing Address - Phone:304-290-5239
Mailing Address - Fax:
Practice Address - Street 1:17978 SR 55
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:WV
Practice Address - Zip Code:26801
Practice Address - Country:US
Practice Address - Phone:304-897-5915
Practice Address - Fax:304-897-6216
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2681124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist