Provider Demographics
NPI:1225152952
Name:THEODOROU PROFESSIONAL DENTAL CORP.
Entity Type:Organization
Organization Name:THEODOROU PROFESSIONAL DENTAL CORP.
Other - Org Name:THEODROU PROFESSIONAL DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKOLAOS
Authorized Official - Middle Name:
Authorized Official - Last Name:THEODOROU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-709-0090
Mailing Address - Street 1:19717 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91306
Mailing Address - Country:US
Mailing Address - Phone:818-709-0090
Mailing Address - Fax:818-709-6002
Practice Address - Street 1:19717 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91306
Practice Address - Country:US
Practice Address - Phone:818-709-0090
Practice Address - Fax:818-709-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9133901OtherDENTICAL