Provider Demographics
NPI:1174694780
Name:THEOPHILUS, DONALD L (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:THEOPHILUS
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:PO BOX 1203
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68702-1203
Mailing Address - Country:US
Mailing Address - Phone:402-371-1360
Mailing Address - Fax:402-371-1278
Practice Address - Street 1:1105 S 13TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5767
Practice Address - Country:US
Practice Address - Phone:402-371-1360
Practice Address - Fax:402-371-1278
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE39961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE05839OtherBCBS