Provider Demographics
NPI:1588653414
Name:THOM, CHARLES JEFFERSON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JEFFERSON
Last Name:THOM
Suffix:JR
Gender:M
Credentials:DDS
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Mailing Address - Street 1:22922 LOS ALISOS BLVD
Mailing Address - Street 2:STE J
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2856
Mailing Address - Country:US
Mailing Address - Phone:949-855-0176
Mailing Address - Fax:949-837-0171
Practice Address - Street 1:22922 LOS ALISOS BLVD
Practice Address - Street 2:STE J
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2856
Practice Address - Country:US
Practice Address - Phone:949-855-0176
Practice Address - Fax:949-837-0171
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CA30495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist