Provider Demographics
NPI:1932378890
Name:SAGRERA, THOMAS PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PAUL
Last Name:SAGRERA
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 1:2650 BEACH BLVD STE 31
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4517
Mailing Address - Country:US
Mailing Address - Phone:228-273-1689
Mailing Address - Fax:228-388-2051
Practice Address - Street 1:2650 BEACH BLVD STE 31
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4517
Practice Address - Country:US
Practice Address - Phone:228-273-1689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA31971223G0001X
AR38901223G0001X
MS4168-201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8132OtherBLUE CROSS BLUE SHIELD
LA1831972Medicaid
843255OtherUNITED CONCORDIA