Provider Demographics
NPI:1700807328
Name:THOMAS, MICHAEL R (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 CARLSON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2626
Mailing Address - Country:US
Mailing Address - Phone:507-532-3353
Mailing Address - Fax:507-532-3482
Practice Address - Street 1:1511 CARLSON STREET
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2605
Practice Address - Country:US
Practice Address - Phone:507-532-3353
Practice Address - Fax:507-532-3482
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0B12THOtherBLUE CROSS BLUE SHIELD IN
836189OtherUNITED CONCORDIA INS
MN834222900Medicaid