Provider Demographics
NPI:1164819108
Name:TOM, WOODSTOCK (DMD)
Entity Type:Individual
Prefix:DR
First Name:WOODSTOCK
Middle Name:
Last Name:TOM
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 1:4318 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6016
Mailing Address - Country:US
Mailing Address - Phone:702-736-6119
Mailing Address - Fax:
Practice Address - Street 1:4318 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6016
Practice Address - Country:US
Practice Address - Phone:702-736-6119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV65911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice