Provider Demographics
NPI:1568470581
Name:KILGORE, THOMAS BLAKE (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BLAKE
Last Name:KILGORE
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 1:715 ALBANY ST
Mailing Address - Street 2:ROBINSON BUILDING B307
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2526
Mailing Address - Country:US
Mailing Address - Phone:617-638-4650
Mailing Address - Fax:617-638-4970
Practice Address - Street 1:100 EAST NEWTON STREET
Practice Address - Street 2:ROOM 407
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-638-4650
Practice Address - Fax:617-638-4970
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA112111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
16311UHOtherHARVARD
MAX03644OtherBCBS
MA0252921Medicaid
MAX03644OtherBCBS
16311UHOtherHARVARD