Provider Demographics
NPI:1316955271
Name:MIDURA, THEODORE ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ANTHONY
Last Name:MIDURA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 JONATHAN JUDD CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073-9491
Mailing Address - Country:US
Mailing Address - Phone:413-527-5519
Mailing Address - Fax:
Practice Address - Street 1:5 CAMPUS LN
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1429
Practice Address - Country:US
Practice Address - Phone:413-527-2330
Practice Address - Fax:413-527-1242
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist