MEDICARE: THEORAL HEALTH INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	DN20850	FL

General Provider Information

NPI Number	:	1255705273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THEORAL HEALTH INSTITUTE

Provider Business Mailing Address
First Line	:	678 GREENLEAF AVE
Second Line	:
City	:	GLENCOE
State	:	IL
Zip	:	60022-1765
Country	:	US
Telephone Number	:	312-925-0042
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 SW 15TH ST
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-6222
Country	:	US
Telephone Number	:	312-925-0042
Fax Number	:

Authorized Official
Title or Position	:	BOARD MEMBER
Name	:	DR. JASON KORKUS
Credential	:	D.D.S.
Telephone Number	:	312-925-0042

Provider Enumeration Date	:	11/16/2015
Last Update Date	:	11/16/2015

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Directions to “THEORAL HEALTH INSTITUTE ” Practice Location

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