Provider Demographics
NPI:1174726269
Name:MIODUSKI, THEODORE E III (DDS)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:E
Last Name:MIODUSKI
Suffix:III
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 1:2975 GINNALA DR
Mailing Address - Street 2:SUITE #100
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3300
Mailing Address - Country:US
Mailing Address - Phone:970-663-1000
Mailing Address - Fax:970-663-0615
Practice Address - Street 1:2975 GINNALA DR
Practice Address - Street 2:SUITE #100
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3300
Practice Address - Country:US
Practice Address - Phone:970-663-1000
Practice Address - Fax:970-663-0615
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice