Provider Demographics
NPI:1053773614
Name:THEODROS A. ABRAHA DDS PC
Entity type:Organization
Organization Name:THEODROS A. ABRAHA DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODROS
Authorized Official - Middle Name:ARAYA
Authorized Official - Last Name:ABRAHA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-294-4234
Mailing Address - Street 1:4201 UNIVERSITY DR STE 109
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2533
Mailing Address - Country:US
Mailing Address - Phone:919-294-4234
Mailing Address - Fax:
Practice Address - Street 1:4201 UNIVERSITY DR STE 109
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2533
Practice Address - Country:US
Practice Address - Phone:919-294-4234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906536Medicaid