Healthcare Provider Details

I. General information

NPI: 1629308648
Provider Name (Legal Business Name): THEODORE KEITH DHEIN L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8064 S.E. HAROLD ST.
PORTLAND OR
97206-5148
US

IV. Provider business mailing address

8064 S.E. HAROLD ST.
PORTLAND OR
97206-5148
US

V. Phone/Fax

Practice location:
  • Phone: 503-777-6014
  • Fax:
Mailing address:
  • Phone: 503-777-6014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT00524581
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: