Provider Demographics
NPI:1679062236
Name:ROUSE, THOMAS RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICHARD
Last Name:ROUSE
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 1:401 W RICH ST UNIT 317
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4933
Mailing Address - Country:US
Mailing Address - Phone:317-217-0846
Mailing Address - Fax:
Practice Address - Street 1:401 W RICH ST UNIT 317
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4933
Practice Address - Country:US
Practice Address - Phone:317-217-0846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060625122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program