Provider Demographics
NPI:1225172364
Name:TALLBACKA, THOMAS ALFRED (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALFRED
Last Name:TALLBACKA
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 1:2005 W 8TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4759
Mailing Address - Country:US
Mailing Address - Phone:814-452-4418
Mailing Address - Fax:
Practice Address - Street 1:2005 W 8TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4759
Practice Address - Country:US
Practice Address - Phone:814-452-4418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019219L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice