Provider Demographics
NPI:1275307688
Name:DUNNETT, THOMAS ALAN (SOIDC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALAN
Last Name:DUNNETT
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16181 LOGARTO LN
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIT 36180 3D RECONNAISSANCE BATTALION
Practice Address - Street 2:3D MARINE DIVISION
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96389-6180
Practice Address - Country:US
Practice Address - Phone:612-237-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10229199TD1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman