Provider Demographics
NPI:1659474013
Name:MACK, THOMAS MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:MACK
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 1:17215 N 72ND DR
Mailing Address - Street 2:STE A100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:623-582-8384
Mailing Address - Fax:623-582-1722
Practice Address - Street 1:17215 N 72ND DR
Practice Address - Street 2:STE A100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-582-8384
Practice Address - Fax:623-582-1722
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38721223G0001X
NM16821223G0001X
SC36811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice