Provider Demographics
NPI:1942287875
Name:KING, THOMAS J III (DDS MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KING
Suffix:III
Gender:M
Credentials:DDS MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003
Mailing Address - Country:US
Mailing Address - Phone:563-557-1440
Mailing Address - Fax:563-557-7001
Practice Address - Street 1:100 BRYANT ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003
Practice Address - Country:US
Practice Address - Phone:563-557-1440
Practice Address - Fax:563-557-7001
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47958204E00000X
IA083931223S0112X
WI58440151223S0112X
MND114481223S0112X
IL0190267071223S0112X
IA36804204E00000X
WI49434020204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33799700Medicaid
MN190009751OtherRAILROAD MEDICARE
IA0493957Medicaid
MN170198300Medicaid
14582OtherBLUE CROSS BLUE SHIELD
MN170198300Medicaid
MN190009751OtherRAILROAD MEDICARE
IA0493957Medicaid