Provider Demographics
NPI:1629308648
Name:DHEIN, THEODORE KEITH (LD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:KEITH
Last Name:DHEIN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8064 S.E. HAROLD ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5148
Mailing Address - Country:US
Mailing Address - Phone:503-777-6014
Mailing Address - Fax:
Practice Address - Street 1:8064 S.E. HAROLD ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-5148
Practice Address - Country:US
Practice Address - Phone:503-777-6014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT00524581122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist