Provider Demographics
NPI:1790832244
Name:REID, THOMAS ALBERT (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALBERT
Last Name:REID
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 1:601 BROOKMAN DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2065
Mailing Address - Country:US
Mailing Address - Phone:601-833-5454
Mailing Address - Fax:601-833-5628
Practice Address - Street 1:601 BROOKMAN DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2065
Practice Address - Country:US
Practice Address - Phone:601-833-5454
Practice Address - Fax:601-833-5628
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPEDO-257-941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660073Medicaid