Provider Demographics
NPI:1164643276
Name:LEGAN, THOMAS L (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:LEGAN
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 1:614B CAPITOLA AVE.
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010
Mailing Address - Country:US
Mailing Address - Phone:831-464-1600
Mailing Address - Fax:831-464-1712
Practice Address - Street 1:614B CAPITOLA AVE.
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010
Practice Address - Country:US
Practice Address - Phone:831-464-1600
Practice Address - Fax:831-464-1712
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270211223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics