Provider Demographics
NPI:1164125456
Name:FOSSIL DENTAL
Entity Type:Organization
Organization Name:FOSSIL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:THAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:210-888-5832
Mailing Address - Street 1:8142 SHIN OAK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2775
Mailing Address - Country:US
Mailing Address - Phone:210-888-5832
Mailing Address - Fax:
Practice Address - Street 1:8142 SHIN OAK DR STE 100
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2775
Practice Address - Country:US
Practice Address - Phone:210-888-5832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALTER D. THAMES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental