Provider Demographics
NPI:1063585693
Name:HORN, THOMAS OWEN JR (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:OWEN
Last Name:HORN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 BYRD AVE N
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3043
Mailing Address - Country:US
Mailing Address - Phone:601-656-5591
Mailing Address - Fax:
Practice Address - Street 1:247 BYRD AVE N
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3043
Practice Address - Country:US
Practice Address - Phone:601-656-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3004-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014559Medicaid