Provider Demographics
NPI:1407958960
Name:THEODOROU, ANASTASIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANASTASIA
Middle Name:
Last Name:THEODOROU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19111 DETROIT RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1740
Mailing Address - Country:US
Mailing Address - Phone:207-784-4222
Mailing Address - Fax:207-784-8798
Practice Address - Street 1:19111 DETROIT RD STE 204
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-1740
Practice Address - Country:US
Practice Address - Phone:440-356-1000
Practice Address - Fax:440-356-2090
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME37121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402338Medicaid