Provider Demographics
NPI:1821290032
Name:SLACK, THOMAS D (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:SLACK
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 1:2504 E PIKES PEAK AVE
Mailing Address - Street 2:#201
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-7024
Mailing Address - Country:US
Mailing Address - Phone:719-392-8596
Mailing Address - Fax:719-392-8298
Practice Address - Street 1:2504 E PIKES PEAK AVE
Practice Address - Street 2:#201
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-7024
Practice Address - Country:US
Practice Address - Phone:719-392-8596
Practice Address - Fax:719-392-8298
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist