Provider Demographics
NPI:1164595518
Name:THOMAS, MARK ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:THOMAS
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 1:4664 TRAGEN CT SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3533
Mailing Address - Country:US
Mailing Address - Phone:503-364-5607
Mailing Address - Fax:503-362-4647
Practice Address - Street 1:408 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4728
Practice Address - Country:US
Practice Address - Phone:503-362-3032
Practice Address - Fax:503-362-4647
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD62051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082185Medicare ID - Type Unspecified