Individual
THERON WAISATH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
3112 VILLAGE OFFICE PL, CHAMPAIGN, IL 61822-7680
(217) 351-7111
(217) 351-7282
Mailing address
3112 VILLAGE OFFICE PL, CHAMPAIGN, IL 61822-7680
(217) 351-7111
(217) 351-7282
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
019.027879
IL
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
2422
OH
Other
Enumeration date
06/08/2007
Last updated
07/23/2009
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