Provider Demographics
NPI:1356379879
Name:LYCH, THOMAS JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:LYCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6208 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1400
Mailing Address - Country:US
Mailing Address - Phone:505-830-9081
Mailing Address - Fax:505-830-9086
Practice Address - Street 1:6208 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1400
Practice Address - Country:US
Practice Address - Phone:505-830-9081
Practice Address - Fax:505-830-9086
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice