Provider Demographics
NPI:1164732624
Name:THOMAS, FIONN (DMD)
Entity Type:Individual
Prefix:DR
First Name:FIONN
Middle Name:
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:PO BOX 1490
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1490
Mailing Address - Country:US
Mailing Address - Phone:912-764-6149
Mailing Address - Fax:912-764-3863
Practice Address - Street 1:219 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2001
Practice Address - Country:US
Practice Address - Phone:912-764-6149
Practice Address - Fax:912-764-3863
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012170122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000879909BMedicaid