Provider Demographics
NPI:1558723213
Name:THOMAS, BROCH (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROCH
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 N 39TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-7123
Mailing Address - Country:US
Mailing Address - Phone:618-339-0800
Mailing Address - Fax:
Practice Address - Street 1:1920 S STAPLEY DR STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6678
Practice Address - Country:US
Practice Address - Phone:480-545-5300
Practice Address - Fax:480-545-5303
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist