Healthcare Provider Details

I. General information

NPI: 1801353941
Provider Name (Legal Business Name): DERIC D THOMSON MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W EAU GALLIE BLVD
MELBOURNE FL
32935-5958
US

IV. Provider business mailing address

63 FOREST EDGE DR
SAINT JOHNS FL
32259-7311
US

V. Phone/Fax

Practice location:
  • Phone: 322-727-3223
  • Fax: 321-727-9448
Mailing address:
  • Phone: 404-759-4507
  • Fax: 386-438-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN24343
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberME172693
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: