Provider Demographics
NPI:1336293174
Name:THOMAS, TEJJY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TEJJY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 BUTTONWOOD ST
Mailing Address - Street 2:SUITE 1507
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3945
Mailing Address - Country:US
Mailing Address - Phone:215-805-2333
Mailing Address - Fax:
Practice Address - Street 1:220 S 16TH ST
Practice Address - Street 2:SUITE 900
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3322
Practice Address - Country:US
Practice Address - Phone:215-545-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0369171223G0001X
PADS0369171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice