Provider Demographics
NPI:1972042380
Name:THOMAS DENTAL GROUP
Entity Type:Organization
Organization Name:THOMAS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:TARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-333-9951
Mailing Address - Street 1:1133 EAST WEST CONNECTOR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:770-333-9951
Mailing Address - Fax:
Practice Address - Street 1:1133 EAST WEST CONNECTOR
Practice Address - Street 2:SUITE 120
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-333-9951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST COBB SMILES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013527261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental