Provider Demographics
NPI:1255534293
Name:THEODOROU, LARISA (DDS)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:THEODOROU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:
Other - Last Name:CALENDAREV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA424301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D42430OtherDENTI CAL TREATING PROVID