Provider Demographics
NPI:1982601357
Name:DUNHAM, THOMAS STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:STEPHEN
Last Name:DUNHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 DEMERS AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-775-3151
Mailing Address - Fax:701-775-3153
Practice Address - Street 1:3035 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4040
Practice Address - Country:US
Practice Address - Phone:701-775-3151
Practice Address - Fax:701-775-3153
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
870421 G2OtherVSI
ND60300Medicaid
ND00568Medicaid
ND00568Medicaid
NDN8924Medicare PIN
0161450002Medicare NSC
NDT66865Medicare UPIN
N8811Medicare PIN
870421 G2OtherVSI