Provider Demographics
NPI:1174627541
Name:THOMAS, THEODORE BRANDON III (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:BRANDON
Last Name:THOMAS
Suffix:III
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 1:450 MCKOY STREET
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2844
Mailing Address - Country:US
Mailing Address - Phone:910-592-6171
Mailing Address - Fax:
Practice Address - Street 1:450 MCKOY STREET
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2844
Practice Address - Country:US
Practice Address - Phone:910-592-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC48181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8998417Medicaid
NC8998417Medicaid