Healthcare Provider Details

I. General information

NPI: 1710947627
Provider Name (Legal Business Name): THEODORE JOSEPH MAPLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N MAIN ST
ULYSSES KS
67880-2132
US

IV. Provider business mailing address

307 N MAIN ST
ULYSSES KS
67880-2132
US

V. Phone/Fax

Practice location:
  • Phone: 620-356-1221
  • Fax: 620-356-5204
Mailing address:
  • Phone: 620-356-1221
  • Fax: 620-356-5204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4614
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: