Peter J Theodorou, DMD, MS

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

37106 Issued in TX

Practice address

2800 William D Tate Ave Ste 100
Grapevine, TX 76051-4325

Phone

(817) 562-2222

NPI assigned

Mar 15, 2007

Reactivated

Apr 7, 2021

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173916800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1636675200000",
    "number": "1598899049",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2800 WILLIAM D TATE AVE STE 100",
            "city": "GRAPEVINE",
            "state": "TX",
            "postal_code": "760514325",
            "telephone_number": "817-562-2222"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2800 WILLIAM D TATE AVE STE 100",
            "city": "GRAPEVINE",
            "state": "TX",
            "postal_code": "760514325",
            "telephone_number": "817-562-2222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "THEODOROU",
        "first_name": "PETER",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "DMD, MS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-03-15",
        "last_updated": "2021-11-12",
        "certification_date": "2021-11-12",
        "deactivation_date": "2021-03-16",
        "reactivation_date": "2021-04-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "NY",
            "license": "050920",
            "primary": false
        },
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "CA",
            "license": "103444",
            "primary": false
        },
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "TX",
            "license": "37106",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Orthodontics and Dentofacial Orthopedics Dentistry in Grapevine, TX
• Providers in Grapevine, TX by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.