Provider Demographics
NPI:1659720415
Name:CHURCH, THOMAS BRENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRENT
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 9TH TER
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:AL
Mailing Address - Zip Code:35127-2209
Mailing Address - Country:US
Mailing Address - Phone:205-478-3569
Mailing Address - Fax:
Practice Address - Street 1:5528 1ST AVE N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35212-2445
Practice Address - Country:US
Practice Address - Phone:205-592-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-11
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist