Provider Demographics
NPI:1033376884
Name:THOMAS, CORNELL C (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORNELL
Middle Name:C
Last Name:THOMAS
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 1:3737 N KINGS HIGHWAY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115
Mailing Address - Country:US
Mailing Address - Phone:314-389-9990
Mailing Address - Fax:314-389-7722
Practice Address - Street 1:3737 N KINGS HIGHWAY
Practice Address - Street 2:SUITE 108
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115
Practice Address - Country:US
Practice Address - Phone:314-389-9990
Practice Address - Fax:314-389-7722
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400519328Medicaid