Provider Demographics
NPI:1396853404
Name:WASKOW, THOMAS ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROBERT
Last Name:WASKOW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:R
Other - Last Name:WASKOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:716 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4730
Mailing Address - Country:US
Mailing Address - Phone:208-467-1311
Mailing Address - Fax:208-467-1311
Practice Address - Street 1:716 16TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4730
Practice Address - Country:US
Practice Address - Phone:208-467-1311
Practice Address - Fax:208-467-1311
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66D13601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10052OtherREGENCE BLUE SHIELD
ID62984OtherBLUE CROSS