Provider Demographics
NPI:1366632507
Name:THOMAS, TIA MONIQUE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIA
Middle Name:MONIQUE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 EAST-WEST CONNECTOR
Mailing Address - Street 2:STE 120
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:770-333-9951
Mailing Address - Fax:770-333-9953
Practice Address - Street 1:1133 EAST-WEST CONNECTOR
Practice Address - Street 2:STE 120
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-333-9951
Practice Address - Fax:770-333-9953
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice