Provider Demographics
NPI:1871734087
Name:QUILITZ, THEODORE L (DDS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:L
Last Name:QUILITZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S PAULINA ST
Mailing Address - Street 2:COLLEGE OF DENTISTRY; DEPT OMFS (MC 835)
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7211
Mailing Address - Country:US
Mailing Address - Phone:312-355-2713
Mailing Address - Fax:312-996-7461
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:COLLEGE OF DENTISTRY; DEPT OMFS (MC 835)
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7211
Practice Address - Country:US
Practice Address - Phone:312-355-2713
Practice Address - Fax:312-996-7461
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-013905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist