Provider Demographics
NPI:1114199288
Name:DR MARY THOMAS, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:DR MARY THOMAS, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-258-1171
Mailing Address - Street 1:8770 CUYAMACA ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-4373
Mailing Address - Country:US
Mailing Address - Phone:619-258-1171
Mailing Address - Fax:619-258-3553
Practice Address - Street 1:8770 CUYAMACA ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4373
Practice Address - Country:US
Practice Address - Phone:619-258-1171
Practice Address - Fax:619-258-3553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty