=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902807977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN L THEROUX D.D.S,M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2005
-----------------------------------------------------
Last Update Date | 01/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10450 PARK MEADOWS DR
-----------------------------------------------------
City | LONETREE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80124-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-779-0565
-----------------------------------------------------
Fax | 303-790-9376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10450 PARK MEADOWS DR #300
-----------------------------------------------------
City | LONETREE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80124-5529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-779-0565
-----------------------------------------------------
Fax | 303-790-9376
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 7495
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------