Provider Demographics
NPI:1689805582
Name:THEIS, JEFF (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:THEIS
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2318
Mailing Address - Country:US
Mailing Address - Phone:860-666-2009
Mailing Address - Fax:
Practice Address - Street 1:435 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2318
Practice Address - Country:US
Practice Address - Phone:860-666-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099091223X0400X
CT0090541223X0400X
NY0558601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics