Provider Demographics
NPI:1467232504
Name:THEODORE L. DEGENHARDT III , D.D.S ., P.C .
Entity Type:Organization
Organization Name:THEODORE L. DEGENHARDT III , D.D.S ., P.C .
Other - Org Name:DEGENHARDT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEGENHARDT
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-643-6551
Mailing Address - Street 1:2877 CROOKS RD STE A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4717
Mailing Address - Country:US
Mailing Address - Phone:248-643-6551
Mailing Address - Fax:248-539-3538
Practice Address - Street 1:2877 CROOKS RD STE A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4717
Practice Address - Country:US
Practice Address - Phone:248-643-6551
Practice Address - Fax:248-539-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty