Provider Demographics
NPI:1992864011
Name:ARCHIE, THADDOUS L (DDS)
Entity Type:Individual
Prefix:
First Name:THADDOUS
Middle Name:L
Last Name:ARCHIE
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 1:8013 LAGUNA BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7920
Mailing Address - Country:US
Mailing Address - Phone:916-691-6020
Mailing Address - Fax:916-691-6022
Practice Address - Street 1:8013 LAGUNA BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7920
Practice Address - Country:US
Practice Address - Phone:916-691-6020
Practice Address - Fax:916-691-6022
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice