Provider Demographics
NPI:1508889924
Name:DEGENHARDT, THEODORE LOUIS III (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:LOUIS
Last Name:DEGENHARDT
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2877 CROOKS RD
Mailing Address - Street 2:SUITE A
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:
Practice Address - Street 1:2877 CROOKS RD
Practice Address - Street 2:SUITE A
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist