Provider Demographics
NPI:1295757581
Name:CONSTANDELIS, THEODORE NICHOLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:NICHOLAS
Last Name:CONSTANDELIS
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 1:465 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2234
Mailing Address - Country:US
Mailing Address - Phone:973-684-1078
Mailing Address - Fax:973-278-3128
Practice Address - Street 1:465 VALLEY RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2234
Practice Address - Country:US
Practice Address - Phone:973-684-1078
Practice Address - Fax:973-278-3128
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ110191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice