Provider Demographics
NPI:1659444602
Name:KONDOS, THEODORE NICHOLAS (DDS)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:NICHOLAS
Last Name:KONDOS
Suffix:
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:PO BOX 933
Mailing Address - Street 2:2208 N BROADWAY #104
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0933
Mailing Address - Country:US
Mailing Address - Phone:918-647-8266
Mailing Address - Fax:918-647-9118
Practice Address - Street 1:2208 N BROADWAY #104
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-0933
Practice Address - Country:US
Practice Address - Phone:918-647-8266
Practice Address - Fax:918-647-9118
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist