Provider Demographics
NPI:1568676864
Name:FARAGO, THOMAS LOUIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LOUIS
Last Name:FARAGO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 S HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4226
Mailing Address - Country:US
Mailing Address - Phone:406-549-6081
Mailing Address - Fax:406-549-6081
Practice Address - Street 1:1547 S HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4226
Practice Address - Country:US
Practice Address - Phone:406-549-6081
Practice Address - Fax:406-549-6081
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011-3997Medicaid