Provider Demographics
NPI:1134818834
Name:THOMAS, DYLAN MATHEW
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:MATHEW
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42090 BARRYMOORE PL
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6438
Mailing Address - Country:US
Mailing Address - Phone:443-986-2289
Mailing Address - Fax:
Practice Address - Street 1:481 GARRISONVILLE RD STE 105
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1601
Practice Address - Country:US
Practice Address - Phone:540-659-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014185261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice