Provider Demographics
NPI:1689952202
Name:THOMAS, SERENA D (DMD)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:D
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SERENA
Other - Middle Name:D
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:175 OLD TAPPAN RD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 OLD TAPPAN RD
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7042
Practice Address - Country:US
Practice Address - Phone:201-768-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-31
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI02501800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program