Provider Demographics
NPI:1972694636
Name:BROWN, THOMAS J (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:BROWN
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 1:1715 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-1538
Mailing Address - Country:US
Mailing Address - Phone:608-269-7678
Mailing Address - Fax:
Practice Address - Street 1:110 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1877
Practice Address - Country:US
Practice Address - Phone:608-269-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33466800Medicaid