Provider Demographics
NPI:1306082128
Name:THOMAS, BLAIR MICOLE (DMD)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:MICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9128 WORSLEY PARK PL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-8711
Mailing Address - Country:US
Mailing Address - Phone:702-743-9996
Mailing Address - Fax:
Practice Address - Street 1:1001 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4124
Practice Address - Country:US
Practice Address - Phone:702-774-2680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNANO4005272179122300000X
OK1641223S0112X
NVS2-1351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist