Provider Demographics
NPI:1790874204
Name:HARMON, THOMAS JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:HARMON
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 1:3575 LAKE EASTBROOK SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-949-2650
Mailing Address - Fax:616-222-0747
Practice Address - Street 1:3575 LAKE EASTBROOK SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-949-2650
Practice Address - Fax:616-222-0747
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI126981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124055750Medicaid
MI124055750Medicaid