Provider Demographics
NPI:1912113143
Name:HAUSCHILDT, THEODORE CONRAD (DDS)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:CONRAD
Last Name:HAUSCHILDT
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 1:1721 E 19TH AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1251
Mailing Address - Country:US
Mailing Address - Phone:303-861-4311
Mailing Address - Fax:303-832-9102
Practice Address - Street 1:1721 E 19TH AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1251
Practice Address - Country:US
Practice Address - Phone:303-861-4311
Practice Address - Fax:303-832-9102
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist