Provider Demographics
NPI:1174667513
Name:ZAJAC, THOMAS EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EDWARD
Last Name:ZAJAC
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 1:913 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-7014
Mailing Address - Country:US
Mailing Address - Phone:814-944-2698
Mailing Address - Fax:814-944-2698
Practice Address - Street 1:401 N 7TH ST
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-6119
Practice Address - Country:US
Practice Address - Phone:814-943-6550
Practice Address - Fax:814-943-6550
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-022537-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA415051OtherUNITED CONCORDIA
PA0018889660001Medicaid
PA14914OtherDORAL DENTAL
PADS-022537-LOtherSTATE LICENSE NUMBER
PAAZ1244285OtherDEA LICENSE NUMBER