Provider Demographics
NPI:1437137858
Name:HERINGHAUS, THERESA DEOGRACIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:DEOGRACIS
Last Name:HERINGHAUS
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 1:2401 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-8517
Mailing Address - Country:US
Mailing Address - Phone:419-529-0451
Mailing Address - Fax:
Practice Address - Street 1:480 GLESSNER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2056
Practice Address - Country:US
Practice Address - Phone:419-524-7409
Practice Address - Fax:419-526-3870
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH187641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2368736Medicaid