=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629308648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE KEITH DHEIN L.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2010
-----------------------------------------------------
Last Update Date | 01/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8064 S.E. HAROLD ST.
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97206-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-777-6014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8064 S.E. HAROLD ST.
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97206-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-777-6014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122400000X
-----------------------------------------------------
Taxonomy Name | Denturist
-----------------------------------------------------
License Number | DT00524581
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------