THERON CORNELIUS WAISATH DMD Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****79

License Status

NOT RENEWED

Business

Title

DMD

First Name

THERON

Middle

CORNELIUS

Last Name

WAISATH

Business Name

THERON CORNELIUS WAISATH DMD

Original Issue Date

03/04/2009

Effective Date

06/04/2009

Expiration Date

09/30/2012

City

MATTOON

State

Zip

61938

County

COLES

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/14/2012