Provider Demographics
NPI:1720466915
Name:HIGGINS, THOMAS BLAKE
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:BLAKE
Last Name:HIGGINS
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 1:400 S LAFAYETTE ST APT 607
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2598
Mailing Address - Country:US
Mailing Address - Phone:970-390-4662
Mailing Address - Fax:
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD SUITE D-202
Practice Address - Street 2:PO BOX 41
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-926-8486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO002034821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program