Provider Demographics
NPI:1639527377
Name:THAI, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:THAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 PINEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-1584
Mailing Address - Country:US
Mailing Address - Phone:978-460-4048
Mailing Address - Fax:
Practice Address - Street 1:45 PINEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-1584
Practice Address - Country:US
Practice Address - Phone:978-460-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1857324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program