Provider Demographics
NPI:1255705273
Name:THEORAL HEALTH INSTITUTE
Entity type:Organization
Organization Name:THEORAL HEALTH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KORKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-925-0042
Mailing Address - Street 1:678 GREENLEAF AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1765
Mailing Address - Country:US
Mailing Address - Phone:312-925-0042
Mailing Address - Fax:
Practice Address - Street 1:910 SW 15TH ST
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-6222
Practice Address - Country:US
Practice Address - Phone:312-925-0042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN208501223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty