Provider Demographics
NPI:1245665520
Name:PEQUIGNOT, THOMAS FRANKLIN (DDS CCN)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FRANKLIN
Last Name:PEQUIGNOT
Suffix:
Gender:M
Credentials:DDS CCN
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11017 BITTERSWEET DELLS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8155
Mailing Address - Country:US
Mailing Address - Phone:260-672-3266
Mailing Address - Fax:260-672-3266
Practice Address - Street 1:11017 BITTERSWEET DELLS LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-8155
Practice Address - Country:US
Practice Address - Phone:260-672-3266
Practice Address - Fax:260-672-3266
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN6420133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist