Provider Demographics
NPI:1831257252
Name:PAWLIAS, THEODORE JAMES (DDS)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JAMES
Last Name:PAWLIAS
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 1:501 EAST GRANT STREET
Mailing Address - Street 2:UNIT #3
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455
Mailing Address - Country:US
Mailing Address - Phone:309-837-6344
Mailing Address - Fax:309-837-6344
Practice Address - Street 1:501 EAST GRANT STREET
Practice Address - Street 2:UNIT #3
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:309-837-6344
Practice Address - Fax:309-837-6344
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101193Medicaid