Provider Demographics
NPI:1134107907
Name:THOMAS W HERFORT PC
Entity Type:Organization
Organization Name:THOMAS W HERFORT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HERFORT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:906-932-1337
Mailing Address - Street 1:204 N HARRISON STREET
Mailing Address - Street 2:WOODLANDS PROFESSIONAL BUILDING
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1714
Mailing Address - Country:US
Mailing Address - Phone:906-932-1332
Mailing Address - Fax:906-932-4337
Practice Address - Street 1:204 N HARRISON ST
Practice Address - Street 2:WOODLANDS PROFESSIONAL BUILDING
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1714
Practice Address - Country:US
Practice Address - Phone:906-932-1332
Practice Address - Fax:906-932-4337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P17420Medicare ID - Type UnspecifiedPART B