Provider Demographics
NPI:1174764039
Name:THEODOTOU, NICHOLAS (BDS, DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:THEODOTOU
Suffix:
Gender:M
Credentials:BDS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2104
Mailing Address - Country:US
Mailing Address - Phone:912-600-6060
Mailing Address - Fax:
Practice Address - Street 1:506 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2104
Practice Address - Country:US
Practice Address - Phone:912-600-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0115301223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery