Provider Demographics
NPI:1740563253
Name:BRISLIN, THOMAS VINCENT JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:VINCENT
Last Name:BRISLIN
Suffix:JR
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 1:100 E LEHIGH AVE
Mailing Address - Street 2:NAVY MEDICINE SUPPORT COMMAND
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4765 CARMEL MOUNTAIN RD STE 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-6657
Practice Address - Country:US
Practice Address - Phone:858-259-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0388221223S0112X
CADS1042961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery