Healthcare Provider Details

I. General information

NPI: 1902807977
Provider Name (Legal Business Name): KEVIN L THEROUX D.D.S,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 PARK MEADOWS DR
LONETREE CO
80124-5530
US

IV. Provider business mailing address

10450 PARK MEADOWS DR #300
LONETREE CO
80124-5529
US

V. Phone/Fax

Practice location:
  • Phone: 303-779-0565
  • Fax: 303-790-9376
Mailing address:
  • Phone: 303-779-0565
  • Fax: 303-790-9376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7495
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: