TIMOTHY A THEISEN Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****99

License Status

NOT RENEWED

Business

First Name

TIMOTHY A

Last Name

THEISEN

Business Name

TIMOTHY A THEISEN

Original Issue Date

06/29/1989

Effective Date

06/29/1989

Expiration Date

09/30/1990

City

ROCKFORD

State

Zip

61111

County

WINNEBAGO

Controlled Substance Schedule

Ever Disciplined

LastModifiedDate

10/13/2005