Healthcare Provider Details

I. General information

NPI: 1497462147
Provider Name (Legal Business Name): KEVIN MAMOOTTIL THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 W ADAMS ST
PHOENIX AZ
85003-2025
US

IV. Provider business mailing address

1727 E PECOS RD APT 4079
GILBERT AZ
85295-1879
US

V. Phone/Fax

Practice location:
  • Phone: 602-207-8528
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012634
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number063927
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: