Healthcare Provider Details

I. General information

NPI: 1467456749
Provider Name (Legal Business Name): THOMAS MALCOLM WARREN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

2655A OLD SHELL RD
MOBILE AL
36607-2929
US

IV. Provider business mailing address

2655A OLD SHELL RD
MOBILE AL
36607-2929
US

V. Phone/Fax

Practice location:
  • Phone: 251-476-2848
  • Fax: 251-476-9868
Mailing address:
  • Phone: 251-476-2848
  • Fax: 251-476-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3205LN
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: