Provider Demographics
NPI:1427717040
Name:THATCHER, JEREMY ROWAN
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROWAN
Last Name:THATCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 STONE ST
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510
Mailing Address - Country:US
Mailing Address - Phone:304-552-2054
Mailing Address - Fax:
Practice Address - Street 1:20 FAIRLAND DR
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1186
Practice Address - Country:US
Practice Address - Phone:304-552-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126900000XDental ProvidersDental Laboratory Technician