Healthcare Provider Details

I. General information

NPI: 1881181329
Provider Name (Legal Business Name): SOUMYA ANN THOMAS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W 63RD ST
CHICAGO IL
60621-2032
US

IV. Provider business mailing address

859 W ERIE ST APT 601
CHICAGO IL
60642-7297
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 972-898-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34804
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019034244
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: