Provider Demographics
NPI:1124498779
Name:THEODORY, TAMER GEORGE I (DDS)
Entity type:Individual
Prefix:
First Name:TAMER
Middle Name:GEORGE I
Last Name:THEODORY
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:UNIVERSITY OF NEW ENGLAND COLLEGE OF DENTAL MEDICINE
Mailing Address - Street 2:716 STEVENS AVENUE
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-221-4863
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF NEW ENGLAND COLLEGE OF DENTAL MEDICINE
Practice Address - Street 2:716 STEVENS AVENUE
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-221-4863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30451390200000X
MEFDN23122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program