Provider Demographics
NPI:1467683011
Name:FELLMAN, THOMAS GLEN (DDS LTD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GLEN
Last Name:FELLMAN
Suffix:
Gender:M
Credentials:DDS LTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 S. UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-232-8884
Mailing Address - Fax:701-232-6064
Practice Address - Street 1:3115 S. UNIVERSITY DR.
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-232-8884
Practice Address - Fax:701-232-6064
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice