Provider Demographics
NPI:1194974865
Name:POWELL, THOMAS VINCENT JR (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:VINCENT
Last Name:POWELL
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 WEST 95TH STREET
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805
Mailing Address - Country:US
Mailing Address - Phone:708-425-8880
Mailing Address - Fax:
Practice Address - Street 1:3860 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2034
Practice Address - Country:US
Practice Address - Phone:708-425-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0200901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice