Provider Demographics
NPI:1013267467
Name:THEKKETHOTTIYIL, GEORGEA B (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGEA
Middle Name:B
Last Name:THEKKETHOTTIYIL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WINDSORGATE WAY
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3698
Mailing Address - Country:US
Mailing Address - Phone:267-241-8248
Mailing Address - Fax:
Practice Address - Street 1:109 WINDSORGATE WAY
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3698
Practice Address - Country:US
Practice Address - Phone:267-241-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029190122300000X
SC85981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist