Provider Demographics
NPI:1295951317
Name:DANIELS, THOMAS ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLEN
Last Name:DANIELS
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 1:6050 BRYNWOOD DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6579
Mailing Address - Country:US
Mailing Address - Phone:815-877-7079
Mailing Address - Fax:
Practice Address - Street 1:6050 BRYNWOOD DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6579
Practice Address - Country:US
Practice Address - Phone:815-877-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics