1376539619 NPI number — DR. CHARLES NORMAN THEOBALD DDS

Table of content: DR. CHARLES NORMAN THEOBALD DDS (NPI 1376539619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376539619 NPI number — DR. CHARLES NORMAN THEOBALD DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEOBALD
Provider First Name:
CHARLES
Provider Middle Name:
NORMAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376539619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/24/2006
NPI Reactivation Date:
04/10/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W COUNTY LINE RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
HIGHLANDS RANCH
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80129-2360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-791-0413
Provider Business Mailing Address Fax Number:
303-791-2341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W COUNTY LINE RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
HIGHLANDS RANCH
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80129-2360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-791-0413
Provider Business Practice Location Address Fax Number:
303-791-2341
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  HDI00291 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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