Provider Demographics
NPI:1104918440
Name:MCGOWAN, THOMAS V (DMD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:V
Last Name:MCGOWAN
Suffix:
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:PO BOX 1040
Mailing Address - Street 2:1150 12TH ST
Mailing Address - City:CHALLIS
Mailing Address - State:ID
Mailing Address - Zip Code:83226-1040
Mailing Address - Country:US
Mailing Address - Phone:208-879-2366
Mailing Address - Fax:208-879-4895
Practice Address - Street 1:1150 12TH ST
Practice Address - Street 2:
Practice Address - City:CHALLIS
Practice Address - State:ID
Practice Address - Zip Code:83226-1040
Practice Address - Country:US
Practice Address - Phone:208-879-2366
Practice Address - Fax:208-879-4895
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist