Provider Demographics
NPI:1154474666
Name:THIBAULT, THOMAS JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BOSTON POST RD.
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1613
Mailing Address - Country:US
Mailing Address - Phone:860-739-3190
Mailing Address - Fax:860-739-0060
Practice Address - Street 1:208 BOSTON POST RD.
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1613
Practice Address - Country:US
Practice Address - Phone:860-739-3190
Practice Address - Fax:860-739-0060
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics