Provider Demographics
NPI:1245374107
Name:MAGNETTI, THOMAS RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICHARD
Last Name:MAGNETTI
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 1:2646 LOIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3500
Mailing Address - Country:US
Mailing Address - Phone:219-762-4266
Mailing Address - Fax:219-762-2252
Practice Address - Street 1:2646 LOIS ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3500
Practice Address - Country:US
Practice Address - Phone:219-762-4266
Practice Address - Fax:219-762-2252
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN65131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice