Provider Demographics
NPI:1902907843
Name:THEIS, DAVID ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
Last Name:THEIS
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 1:1674 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-4961
Mailing Address - Country:US
Mailing Address - Phone:386-789-5100
Mailing Address - Fax:386-789-5116
Practice Address - Street 1:1674 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-4961
Practice Address - Country:US
Practice Address - Phone:386-789-5100
Practice Address - Fax:386-789-5116
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 56711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice