Provider Demographics
NPI:1871756767
Name:THEODORE, IRENE T (DDS)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:T
Last Name:THEODORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W PETERSON AVE
Mailing Address - Street 2:SUITE 136
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6074
Mailing Address - Country:US
Mailing Address - Phone:773-286-5286
Mailing Address - Fax:773-286-5331
Practice Address - Street 1:4200 W PETERSON AVE
Practice Address - Street 2:SUITE 136
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6074
Practice Address - Country:US
Practice Address - Phone:773-286-5286
Practice Address - Fax:773-286-5331
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190209031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice