Provider Demographics
NPI:1275636615
Name:TOM L POOLEY
Entity Type:Organization
Organization Name:TOM L POOLEY
Other - Org Name:RIVER VALLEY DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:L
Authorized Official - Last Name:POOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-388-3384
Mailing Address - Street 1:124 E WALNUT ST
Mailing Address - Street 2:STE 300
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-388-3384
Mailing Address - Fax:507-388-6079
Practice Address - Street 1:124 E WALNUT ST
Practice Address - Street 2:STE 300
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-388-3384
Practice Address - Fax:507-388-6079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty