MEDICARE: MARVETTE EVONNE THOMAS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401410133	VA

General Provider Information

NPI Number	:	1992851851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVETTE EVONNE THOMAS DDS

Provider Business Mailing Address
First Line	:	12351 DILLINGHAM SQUARE
Second Line	:
City	:	LAKE RDIGE
State	:	VA
Zip	:	22192
Country	:	US
Telephone Number	:	703-580-8288
Fax Number	:	703-590-2382

Provider Business Practice Location Address
First Line	:	12351 DILLINGHAM SQ
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-5251
Country	:	US
Telephone Number	:	703-580-8288
Fax Number	:	703-590-2382

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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