Provider Demographics
NPI:1700803228
Name:THEODORE G. MUCHITENI, DMD, PA
Entity Type:Organization
Organization Name:THEODORE G. MUCHITENI, DMD, PA
Other - Org Name:GREENVILLE ORAL & MAXILLOFACIAL SURGEONS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:MUCHITENI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:252-830-0201
Mailing Address - Street 1:2300 HEMBY LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3775
Mailing Address - Country:US
Mailing Address - Phone:252-830-0201
Mailing Address - Fax:252-830-2052
Practice Address - Street 1:2300 HEMBY LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3775
Practice Address - Country:US
Practice Address - Phone:252-830-0201
Practice Address - Fax:252-830-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6996278Medicaid
NC6996278Medicaid