Provider Demographics
NPI:1073672242
Name:THOMLEY, JERRY DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DAVID
Last Name:THOMLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-5701
Mailing Address - Country:US
Mailing Address - Phone:334-365-2991
Mailing Address - Fax:334-365-2991
Practice Address - Street 1:745 DAVIS ST
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-5701
Practice Address - Country:US
Practice Address - Phone:334-365-2991
Practice Address - Fax:334-365-2991
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009958965Medicaid