Provider Demographics
NPI:1336267905
Name:THOMAS, NICOLA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 BLANTYRE BLVD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5499
Mailing Address - Country:US
Mailing Address - Phone:678-714-7011
Mailing Address - Fax:678-714-8388
Practice Address - Street 1:2119 HAMILTON CREEK PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-3293
Practice Address - Country:US
Practice Address - Phone:678-714-7011
Practice Address - Fax:678-714-8388
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA278046528AMedicaid