Provider Demographics
NPI:1053373092
Name:AMEREDES, THEODORE (DDS)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:AMEREDES
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 1:1433 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5126
Mailing Address - Country:US
Mailing Address - Phone:412-680-0366
Mailing Address - Fax:
Practice Address - Street 1:1433 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5126
Practice Address - Country:US
Practice Address - Phone:412-680-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015259710003Medicaid
PA1015259710008Medicaid
PA1015259710009Medicaid
PA1015259710002Medicaid
PA1015259710005Medicaid
PA1015259710011Medicaid
PA1015259710004Medicaid
PA1015259710006Medicaid
PA1015259710007Medicaid
PA1015259710012Medicaid
PA1015259710010Medicaid
PA1015259710013Medicaid
PA1015259710001Medicaid