Provider Demographics
NPI:1033372412
Name:THOMAS BACKENSTOSE DMD INC
Entity Type:Organization
Organization Name:THOMAS BACKENSTOSE DMD INC
Other - Org Name:DR. THOMAS BACKENSTOSE PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:BACKENSTOSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-641-0641
Mailing Address - Street 1:901 SUNSET DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422
Mailing Address - Country:US
Mailing Address - Phone:215-641-0641
Mailing Address - Fax:215-583-5222
Practice Address - Street 1:901 SUNSET DRIVE
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422
Practice Address - Country:US
Practice Address - Phone:215-641-0641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10848261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental