Healthcare Provider Details

I. General information

NPI: 1033491600
Provider Name (Legal Business Name): DR. THOMAS GABRIEL HOTARD I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S PINETREE BLVD DENTAL CLINIC, BLDG. 510
THOMASVILLE GA
31792-7128
US

IV. Provider business mailing address

P.O. BOX 1378 400 S. PINETREE BLVD. SOUTHWESTERN STATE HOSPITAL,
THOMASVILLE GA
31799-1378
US

V. Phone/Fax

Practice location:
  • Phone: 229-227-2817
  • Fax: 229-227-3206
Mailing address:
  • Phone: 229-227-2817
  • Fax: 229-227-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number000732
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: