Provider Demographics
NPI:1326170663
Name:THOMAS, JERRY LAMAR
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LAMAR
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARTIN LUTHER KING JR CT
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-3656
Mailing Address - Country:US
Mailing Address - Phone:706-884-8009
Mailing Address - Fax:
Practice Address - Street 1:128 MARTIN LUTHER KING JR CT
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3656
Practice Address - Country:US
Practice Address - Phone:706-884-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223D0001X1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health