Provider Demographics
NPI:1093027450
Name:THOMAS, LETACIA DENISE (MD)
Entity Type:Individual
Prefix:
First Name:LETACIA
Middle Name:DENISE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16037 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1309
Mailing Address - Country:US
Mailing Address - Phone:404-429-0432
Mailing Address - Fax:
Practice Address - Street 1:33155 ANNAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:313-436-2577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine