Provider Demographics
NPI:1417146754
Name:GILBERT, THOMAS M
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:GILBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6897
Mailing Address - Country:US
Mailing Address - Phone:260-432-0561
Mailing Address - Fax:260-436-4626
Practice Address - Street 1:4626 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6897
Practice Address - Country:US
Practice Address - Phone:260-432-0561
Practice Address - Fax:260-436-4626
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN9757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist