Provider Demographics
NPI:1811281637
Name:THEVENIN, MARC CONEL JR (DDS)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:CONEL
Last Name:THEVENIN
Suffix:JR
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 1:2095 CLEMENTI LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-8579
Mailing Address - Country:US
Mailing Address - Phone:909-810-6292
Mailing Address - Fax:
Practice Address - Street 1:5270 ELMORE AVE STE 4
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3437
Practice Address - Country:US
Practice Address - Phone:563-209-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030600122300000X
390200000X
IADDS-10298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program