Active NPI
Theodore Petridis
- Dentist
- Brandon, FL
National Provider Identifier
1124877139
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- DN29005
- Practice address
- 2468 W Brandon Blvd
Brandon, FL 33511-4717 - Phone
- (813) 257-9518
- NPI assigned
- May 14, 2024
- Last updated
- Sep 1, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DN29005 | FL | Primary |
Addresses
Primary practice location
2468 W Brandon Blvd
Brandon, FL 33511-4717
Mailing address
9958 Jonas Salk Dr Apt 428
Riverview, FL 33578-7455
Other practice location 1
13023 US Highway 301 S
Riverview, FL 33578-7439
Phone (813) 518-5542
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN29005 | FL | MD | Dentist |
Networks
- Freedom Health HMO Network
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1715644800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1756684800000",
"number": "1124877139",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9958 JONAS SALK DR APT 428",
"city": "RIVERVIEW",
"state": "FL",
"postal_code": "335787455"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2468 W BRANDON BLVD",
"city": "BRANDON",
"state": "FL",
"postal_code": "335114717",
"telephone_number": "813-257-9518"
}
],
"practiceLocations": [
{
"address_1": "13023 US Highway 301 S",
"address_purpose": "LOCATION",
"city": "Riverview",
"state": "FL",
"postal_code": "335787439",
"country_code": "US",
"telephone_number": "813-518-5542",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PETRIDIS",
"first_name": "THEODORE",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2024-05-14",
"last_updated": "2025-09-01",
"certification_date": "2025-09-01",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "FL",
"license": "DN29005",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Brandon, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.