1356730741 NPI number — DAVID E THOME DDS PLLC IV

Table of content: (NPI 1356730741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356730741 NPI number — DAVID E THOME DDS PLLC IV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID E THOME DDS PLLC IV
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STATESVILLE PEDIATRIC DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356730741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 530172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30353-0172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-729-5200
Provider Business Mailing Address Fax Number:
704-943-0593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1454 FERN CREEK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-223-2607
Provider Business Practice Location Address Fax Number:
980-223-6064
Provider Enumeration Date:
01/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
LUCENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING & CONTRACTING COORDIN
Authorized Official Telephone Number:
980-729-5200

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  9277 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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