Provider Demographics
NPI:1295972644
Name:W. A. THAMES, DMD
Entity type:Organization
Organization Name:W. A. THAMES, DMD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:THAMES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-963-7338
Mailing Address - Street 1:228 MAIN STREET
Mailing Address - Street 2:BOX 388
Mailing Address - City:NETTLETON
Mailing Address - State:MS
Mailing Address - Zip Code:38858
Mailing Address - Country:US
Mailing Address - Phone:662-963-7338
Mailing Address - Fax:662-963-7339
Practice Address - Street 1:228 MAIN STREET
Practice Address - Street 2:BOX 388
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858
Practice Address - Country:US
Practice Address - Phone:662-963-7338
Practice Address - Fax:662-963-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2204-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060277Medicaid