Provider Demographics
NPI:1306190285
Name:BRENT THOMAS DMD PA
Entity Type:Organization
Organization Name:BRENT THOMAS DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-638-2361
Mailing Address - Street 1:1805 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3709
Mailing Address - Country:US
Mailing Address - Phone:601-638-2361
Mailing Address - Fax:601-634-0864
Practice Address - Street 1:1805 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3709
Practice Address - Country:US
Practice Address - Phone:601-638-2361
Practice Address - Fax:601-634-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1953811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1649492695OtherNPI INDIVIDUAL