Provider Demographics
NPI:1104698240
Name:THEZINE, APOLLON III
Entity type:Individual
Prefix:
First Name:APOLLON III
Middle Name:
Last Name:THEZINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 W HIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:DODGE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55927-9063
Mailing Address - Country:US
Mailing Address - Phone:507-374-6635
Mailing Address - Fax:507-374-2277
Practice Address - Street 1:406 W HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:DODGE CENTER
Practice Address - State:MN
Practice Address - Zip Code:55927-9063
Practice Address - Country:US
Practice Address - Phone:507-374-6635
Practice Address - Fax:507-374-2277
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND150101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice