Provider Demographics
NPI:1588876908
Name:THOMAS, GRACE (DDS)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MAINE MALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2310
Mailing Address - Country:US
Mailing Address - Phone:207-775-1551
Mailing Address - Fax:
Practice Address - Street 1:171 MAINE MALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2310
Practice Address - Country:US
Practice Address - Phone:207-775-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME40521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU97339Medicare UPIN