Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | RES.004068 | OH |
NPI | 1144882242 |
---|---|
Provider Name | Kalia Theodorou |
First Address | Columbus, OH 43215-3676 |
Second Address | Columbus, OH 43210-1267 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2019 |
Last Update Date | 28/06/2019 |