Provider Demographics
NPI:1073522272
Name:THOMAS, RICHARD NELSON (DENTIST DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:NELSON
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DENTIST DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ALABAMA ST
Mailing Address - Street 2:STE A
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2518
Mailing Address - Country:US
Mailing Address - Phone:850-682-4516
Mailing Address - Fax:850-682-4498
Practice Address - Street 1:102 ALABAMA ST
Practice Address - Street 2:STE A
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2518
Practice Address - Country:US
Practice Address - Phone:850-682-4516
Practice Address - Fax:850-682-4498
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL71001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice