Provider Demographics
NPI:1083168363
Name:THOMAS C FLAVIN DDS
Entity Type:Organization
Organization Name:THOMAS C FLAVIN DDS
Other - Org Name:HEALTHY SMILES OF ST. LOUIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:FLAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-832-1366
Mailing Address - Street 1:PO BOX 3000
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-8001
Mailing Address - Country:US
Mailing Address - Phone:800-544-2345
Mailing Address - Fax:503-315-7227
Practice Address - Street 1:4224 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1210
Practice Address - Country:US
Practice Address - Phone:314-832-1366
Practice Address - Fax:314-832-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO136141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty