Provider Demographics
NPI:1619369741
Name:THOMAS FAMILY DENTAL II LLC
Entity Type:Organization
Organization Name:THOMAS FAMILY DENTAL II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-348-7681
Mailing Address - Street 1:137 FALLOWFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-1402
Mailing Address - Country:US
Mailing Address - Phone:724-483-4462
Mailing Address - Fax:
Practice Address - Street 1:137 FALLOWFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLEROI
Practice Address - State:PA
Practice Address - Zip Code:15022-1402
Practice Address - Country:US
Practice Address - Phone:724-483-4462
Practice Address - Fax:724-565-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027841-L302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization