Provider Demographics
NPI:1477558138
Name:TOM, MICHAEL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:TOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1220 MEDICAL PARK DR
Mailing Address - Street 2:STE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5843
Mailing Address - Country:US
Mailing Address - Phone:260-482-9196
Mailing Address - Fax:260-484-3371
Practice Address - Street 1:1220 MEDICAL PARK DR
Practice Address - Street 2:STE 1
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5843
Practice Address - Country:US
Practice Address - Phone:260-482-9196
Practice Address - Fax:260-484-3371
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010084A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist