Provider Demographics
NPI:1285896530
Name:THOMAS DENTAL OFFICE PC
Entity type:Organization
Organization Name:THOMAS DENTAL OFFICE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTAL ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEAVAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-389-9990
Mailing Address - Street 1:3737 N KINGSHIGHWAY BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-1736
Mailing Address - Country:US
Mailing Address - Phone:314-389-7722
Mailing Address - Fax:
Practice Address - Street 1:3737 N KINGSHIGHWAY BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1736
Practice Address - Country:US
Practice Address - Phone:314-389-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400519328Medicaid
WI002362OtherDORAL DENTAL