Provider Demographics
NPI:1023212354
Name:THOMAS R. BACON, DDS,PA
Entity Type:Organization
Organization Name:THOMAS R. BACON, DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-542-5197
Mailing Address - Street 1:PO BOX 1435
Mailing Address - Street 2:200 BROAD STREET
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-1435
Mailing Address - Country:US
Mailing Address - Phone:603-542-5197
Mailing Address - Fax:603-542-3531
Practice Address - Street 1:200 BROAD STREET
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-1435
Practice Address - Country:US
Practice Address - Phone:603-542-5197
Practice Address - Fax:603-542-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty