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General NPI Number Information
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NPI Number | 1871756767
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Entity Type | Individual
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Provider Name | IRENE T. THEODORE DDS
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Gender | Female
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Dates
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Enumeration Date | 07/09/2008
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Last Update Date | 07/17/2008
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Provider Practice Location Address
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Address Line | 4200 W PETERSON AVE SUITE 136
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City | CHICAGO
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State | IL
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Zip | 60646-6074
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Country | US
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Telephone | 773-286-5286
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Fax | 773-286-5331
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Provider Business Mailing Address
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Address Line | 4200 W PETERSON AVE SUITE 136
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City | CHICAGO
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State | IL
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Zip | 60646-6074
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Country | US
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Telephone | 773-286-5286
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Fax | 773-286-5331
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 019020903
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License Number State | IL
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