Provider Demographics
NPI:1649492695
Name:THOMAS, CHARLES BRENT (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRENT
Last Name:THOMAS
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 1:1805 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3709
Mailing Address - Country:US
Mailing Address - Phone:601-638-2361
Mailing Address - Fax:601-634-0864
Practice Address - Street 1:1805 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3709
Practice Address - Country:US
Practice Address - Phone:601-638-2361
Practice Address - Fax:601-634-0864
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1953811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice