MEDICARE: DR. THEODORE ALBERT MCWILLIE D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2103	NV

General Provider Information

NPI Number	:	1083800429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE ALBERT MCWILLIE D.D.S.

Provider Business Mailing Address
First Line	:	4660 S EASTERN AVE
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6137
Country	:	US
Telephone Number	:	702-456-0005
Fax Number	:

Provider Business Practice Location Address
First Line	:	4660 S EASTERN AVE
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6137
Country	:	US
Telephone Number	:	702-456-0005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	09/19/2007

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