Provider Demographics
NPI:1962789701
Name:THEODOROU, JOHN S (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:THEODOROU
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 1:19380 COLLINS AVE
Mailing Address - Street 2:UNIT 1122-B
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2239
Mailing Address - Country:US
Mailing Address - Phone:305-801-7537
Mailing Address - Fax:
Practice Address - Street 1:19380 COLLINS AVE
Practice Address - Street 2:UNIT 1122-B
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-2239
Practice Address - Country:US
Practice Address - Phone:305-801-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN3019122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist