Provider Demographics
NPI:1265698815
Name:THOBABEN, JOHN ZECHARIAH (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ZECHARIAH
Last Name:THOBABEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MERIDIAN WAY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
Mailing Address - Country:US
Mailing Address - Phone:859-361-8058
Mailing Address - Fax:
Practice Address - Street 1:120 MERIDIAN WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-361-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018.0016251223P0221X
KY84661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100082750Medicaid
IL018.001625OtherIL TEMPORARY STATE DENTAL LICENSE