Provider Demographics
NPI:1780648642
Name:TOMELIN, THOMAS E (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:TOMELIN
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 1:1401 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3313
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:859-655-6148
Practice Address - Street 1:103 LANDMARK DR
Practice Address - Street 2:LL2
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073
Practice Address - Country:US
Practice Address - Phone:859-655-6100
Practice Address - Fax:859-655-6148
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30019585122300000X
KY55961223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60055969Medicaid
OH123440Medicaid