Provider Demographics
NPI:1386093755
Name:LAYER, THERON (DDS)
Entity type:Individual
Prefix:DR
First Name:THERON
Middle Name:
Last Name:LAYER
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 1:4736 LACEY AVE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1892
Mailing Address - Country:US
Mailing Address - Phone:319-671-1233
Mailing Address - Fax:
Practice Address - Street 1:2563 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2051
Practice Address - Country:US
Practice Address - Phone:319-671-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190308261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice