Provider Demographics
NPI:1942320536
Name:FLATH, THOMAS JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JACOB
Last Name:FLATH
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 1:2075 SW 1ST AVE STE 2K
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5314
Mailing Address - Country:US
Mailing Address - Phone:503-222-3591
Mailing Address - Fax:503-222-4496
Practice Address - Street 1:2075 SW 1ST AVE STE 2K
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5314
Practice Address - Country:US
Practice Address - Phone:503-222-3591
Practice Address - Fax:503-222-4496
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD97161223G0001X
ORD82761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice