Provider Demographics
NPI:1902807977
Name:THEROUX, KEVIN L (DDS,MS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:THEROUX
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10450 PARK MEADOWS DR
Mailing Address - Street 2:#300
Mailing Address - City:LONETREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5529
Mailing Address - Country:US
Mailing Address - Phone:303-779-0565
Mailing Address - Fax:303-790-9376
Practice Address - Street 1:10450 PARK MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LONETREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5530
Practice Address - Country:US
Practice Address - Phone:303-779-0565
Practice Address - Fax:303-790-9376
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO74951223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
472501459OtherEIN