Provider Demographics
NPI:1760542245
Name:YOUNGBLOOD, THOMAS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:YOUNGBLOOD
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 1:100 N N ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6409
Mailing Address - Country:US
Mailing Address - Phone:432-682-1614
Mailing Address - Fax:432-685-3405
Practice Address - Street 1:100 N N ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6409
Practice Address - Country:US
Practice Address - Phone:432-682-1614
Practice Address - Fax:432-685-3405
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5620122300000X
TX21026122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1862898Medicaid