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General NPI Number Information
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NPI Number | 1467232504
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Entity Type | Organization
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Legal Business Name | THEODORE L. DEGENHARDT III , D.D.S ., P.C .
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Dates
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Enumeration Date | 10/05/2023
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Last Update Date | 11/20/2023
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Provider Practice Location Address
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Address Line | 2877 CROOKS RD STE A
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City | TROY
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State | MI
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Zip | 48084-4717
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Country | US
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Telephone | 248-643-6551
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Fax | 248-539-3538
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Provider Business Mailing Address
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Address Line | 2877 CROOKS RD STE A
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City | TROY
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State | MI
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Zip | 48084-4717
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Country | US
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Telephone | 248-643-6551
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Fax | 248-539-3538
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Authorized Official
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Title or Position | OWNER
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Name | DR. THEODORE L. DEGENHARDT III
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Credential | DDS
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Telephone | 248-643-6551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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