Provider Demographics
NPI:1760102628
Name:STEVEN P. THEODOSIS DENTAL CORPORATION
Entity Type:Organization
Organization Name:STEVEN P. THEODOSIS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:THEODOSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-778-1423
Mailing Address - Street 1:23911 DANZIG BAY
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7805 HIGHLAND VILLAGE PL STE G105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-5181
Practice Address - Country:US
Practice Address - Phone:650-922-0897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental