Provider Demographics
NPI:1023114071
Name:DOUGLAS, THOMAS R (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:DOUGLAS
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 1:308 GIBBS POND RD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2200
Mailing Address - Country:US
Mailing Address - Phone:631-585-3130
Mailing Address - Fax:631-585-3136
Practice Address - Street 1:308 GIBBS POND RD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2200
Practice Address - Country:US
Practice Address - Phone:631-585-3130
Practice Address - Fax:631-585-3136
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY0477140122300000X
NJNJ22D102047200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist