Provider Demographics
NPI:1902108897
Name:THEODORE, KEITH FELIX (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:FELIX
Last Name:THEODORE
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 1:16729 QUEEN ANNE RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-8754
Mailing Address - Country:US
Mailing Address - Phone:301-613-2430
Mailing Address - Fax:
Practice Address - Street 1:16729 QUEEN ANNE RD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-8754
Practice Address - Country:US
Practice Address - Phone:301-613-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-26
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD73991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1164519385Medicaid