Provider Demographics
NPI:1356310122
Name:THOMAS, WALTER M (DMD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:M
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 1:906 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CONNEAUTVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16406-7138
Mailing Address - Country:US
Mailing Address - Phone:814-373-2284
Mailing Address - Fax:814-587-6579
Practice Address - Street 1:906 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CONNEAUTVILLE
Practice Address - State:PA
Practice Address - Zip Code:16406-7138
Practice Address - Country:US
Practice Address - Phone:814-373-2284
Practice Address - Fax:814-587-6579
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025737L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010954660002Medicaid
PA0010954660002Medicaid