Provider Demographics
NPI:1023193182
Name:FORMANACK, THOMAS J (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:FORMANACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16597 HASCALL ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2060
Mailing Address - Country:US
Mailing Address - Phone:402-697-9401
Mailing Address - Fax:402-758-0030
Practice Address - Street 1:17775 MASON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-3559
Practice Address - Country:US
Practice Address - Phone:402-758-9399
Practice Address - Fax:402-758-0030
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE40241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice