Healthcare Provider Details

I. General information

NPI: 1407958960
Provider Name (Legal Business Name): ANASTASIA THEODOROU D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19111 DETROIT RD STE 204
ROCKY RIVER OH
44116-1740
US

IV. Provider business mailing address

19111 DETROIT RD STE 206
ROCKY RIVER OH
44116-1740
US

V. Phone/Fax

Practice location:
  • Phone: 440-356-1000
  • Fax: 440-356-2090
Mailing address:
  • Phone: 207-784-4222
  • Fax: 207-784-8798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3712
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: