Provider Demographics
NPI:1497115877
Name:KRISTI THOMAS, DDS, PORTABLE PRACTICE, PC
Entity Type:Organization
Organization Name:KRISTI THOMAS, DDS, PORTABLE PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-576-2554
Mailing Address - Street 1:7310 WOODWARD AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3165
Mailing Address - Country:US
Mailing Address - Phone:313-576-2557
Mailing Address - Fax:
Practice Address - Street 1:7310 WOODWARD AVE
Practice Address - Street 2:STE 400
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3165
Practice Address - Country:US
Practice Address - Phone:313-576-2557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010178761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty