Provider Demographics
NPI:1528083938
Name:THEOFILOS, ANNETTE CONSTANCE (DMD)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:CONSTANCE
Last Name:THEOFILOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 SHENANGO VALLEY FWY
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-2544
Mailing Address - Country:US
Mailing Address - Phone:724-346-5173
Mailing Address - Fax:
Practice Address - Street 1:255 CHARLESTON RD
Practice Address - Street 2:
Practice Address - City:SHARPSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16150-3303
Practice Address - Country:US
Practice Address - Phone:724-962-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028955L1223G0001X
OH30.020094122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice