Provider Demographics
NPI:1750576690
Name:KALLAL, THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KALLAL
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:N5027 JOE CORN DR
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-9543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13924 WADAGA RD
Practice Address - Street 2:
Practice Address - City:BARAGA
Practice Address - State:MI
Practice Address - Zip Code:49908-9204
Practice Address - Country:US
Practice Address - Phone:906-353-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist