Provider Demographics
NPI:1144393034
Name:THOMAS, PHELAN RICO (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHELAN
Middle Name:RICO
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 UNIVERSITY AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5958
Mailing Address - Country:US
Mailing Address - Phone:515-223-8800
Mailing Address - Fax:515-223-1437
Practice Address - Street 1:4100 UNIVERSITY AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-5956
Practice Address - Country:US
Practice Address - Phone:515-223-8800
Practice Address - Fax:515-223-1437
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07198122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07198OtherDENTAL LICENSE NUMBER