Provider Demographics
NPI:1699918037
Name:BROWN, THOMAS ALLEN JR (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLEN
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1414 KINGSLEY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-269-4201
Mailing Address - Fax:904-269-1163
Practice Address - Street 1:1414 KINGSLEY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-269-4201
Practice Address - Fax:904-269-1163
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN183701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001049300Medicaid