Provider Demographics
NPI:1598899049
Name:THEODOROU, PETER J (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:THEODOROU
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 WILLIAM D TATE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-4325
Mailing Address - Country:US
Mailing Address - Phone:817-562-2222
Mailing Address - Fax:
Practice Address - Street 1:2800 WILLIAM D TATE AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4325
Practice Address - Country:US
Practice Address - Phone:817-562-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2021-11-12
Deactivation Date:2021-03-16
Deactivation Code:
Reactivation Date:2021-04-07
Provider Licenses
StateLicense IDTaxonomies
NY0509201223X0400X
CA1034441223X0400X
TX371061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics