Healthcare Provider Details

I. General information

NPI: 1417172156
Provider Name (Legal Business Name): THERESIA LYNN TITUS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17978 SR 55
BAKER WV
26801
US

IV. Provider business mailing address

1905 MICHAEL AVE
PETERSBURG WV
26847-9460
US

V. Phone/Fax

Practice location:
  • Phone: 304-897-5915
  • Fax: 304-897-6216
Mailing address:
  • Phone: 304-290-5239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2681
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: