Provider Demographics
NPI:1407284763
Name:THORN, TREVOR ROBERT NORMAN (DDS)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ROBERT NORMAN
Last Name:THORN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22629 TWAIN HARTE DR
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9405
Mailing Address - Country:US
Mailing Address - Phone:209-586-2772
Mailing Address - Fax:209-586-4612
Practice Address - Street 1:22629 TWAIN HARTE DR
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9405
Practice Address - Country:US
Practice Address - Phone:209-586-2772
Practice Address - Fax:209-586-4612
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626471223G0001X
CAFT40922611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice