Provider Demographics
NPI:1669433793
Name:SLACK, THOMAS A (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:SLACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3801 GLENKERRY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0718
Mailing Address - Country:US
Mailing Address - Phone:269-323-1527
Mailing Address - Fax:269-323-1670
Practice Address - Street 1:3801 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0718
Practice Address - Country:US
Practice Address - Phone:269-323-1527
Practice Address - Fax:269-323-1670
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010138231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2675451Medicaid
MI2990919Medicaid
MI2990919Medicaid