Provider Demographics
NPI:1649598921
Name:THOMAS R. VIVIAN DMD PLLC
Entity Type:Organization
Organization Name:THOMAS R. VIVIAN DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VIVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-420-2480
Mailing Address - Street 1:10515 MEETING ST
Mailing Address - Street 2:104
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-6523
Mailing Address - Country:US
Mailing Address - Phone:502-420-2480
Mailing Address - Fax:502-420-2891
Practice Address - Street 1:10515 MEETING ST
Practice Address - Street 2:104
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-6523
Practice Address - Country:US
Practice Address - Phone:502-420-2480
Practice Address - Fax:502-420-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty