Provider Demographics
NPI:1457342750
Name:PETERS, THEODORE EDWARD DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:EDWARD DAVID
Last Name:PETERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 SOUTH HABANA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609
Mailing Address - Country:US
Mailing Address - Phone:813-870-1220
Mailing Address - Fax:813-870-2615
Practice Address - Street 1:508 SOUTH HABANA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609
Practice Address - Country:US
Practice Address - Phone:813-870-1220
Practice Address - Fax:813-870-2615
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0013473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist