Healthcare Provider Details

I. General information

NPI: 1619183241
Provider Name (Legal Business Name): MICHAEL W THOMAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 LIDDELL DRIVE
RIDGWAY CO
81432-1083
US

IV. Provider business mailing address

PO BOX 1083 156 LIDDELL DRIVE
RIDGWAY CO
81432-1083
US

V. Phone/Fax

Practice location:
  • Phone: 970-626-3774
  • Fax:
Mailing address:
  • Phone: 970-626-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberHD-1-04983
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: