Provider Demographics
NPI:1003894684
Name:THIBAULT, ALAN (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 S HALSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:HALSTEAD
Mailing Address - State:KS
Mailing Address - Zip Code:67056-9288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 W CENTRAL AVE
Practice Address - Street 2:STE 100
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4928
Practice Address - Country:US
Practice Address - Phone:316-616-1310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS62921223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics