=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295915767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE MARKOS D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2007
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 MEMORIAL DR SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-863-8592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 MEMORIAL DR SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 015154
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN015154
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------