Provider Demographics
NPI:1841726593
Name:JAMES, THEODORE (DDS)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:JAMES
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 1:2677 E 17TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6619
Mailing Address - Country:US
Mailing Address - Phone:208-705-9652
Mailing Address - Fax:
Practice Address - Street 1:2677 E 17TH ST STE 600
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6619
Practice Address - Country:US
Practice Address - Phone:208-705-9652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0414041223S0112X
390200000X
IDD-52581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program