Provider Demographics
NPI:1497156731
Name:THEOBALD, TIMOTHY (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 N NICOLE LN
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2286
Mailing Address - Country:US
Mailing Address - Phone:847-431-4318
Mailing Address - Fax:
Practice Address - Street 1:2127 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-2801
Practice Address - Country:US
Practice Address - Phone:847-336-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0300111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice