Provider Demographics
NPI:1013151505
Name:POTTS, THOMAS VINCENT (DDS, PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:VINCENT
Last Name:POTTS
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WILLETS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:14813-1026
Mailing Address - Country:US
Mailing Address - Phone:585-268-5588
Mailing Address - Fax:
Practice Address - Street 1:26 WILLETS AVENUE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NY
Practice Address - Zip Code:14813-1026
Practice Address - Country:US
Practice Address - Phone:585-268-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00903677Medicaid
NY031451OtherN.Y.S. DEPT. OF EDUCATION DENTAL LICENSE NO.