Healthcare Provider Details

I. General information

NPI: 1992883367
Provider Name (Legal Business Name): GREGORY PAUL THOMAS DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST SUITE 2280
CHICAGO IL
60611-2927
US

IV. Provider business mailing address

676 N SAINT CLAIR ST SUITE 2280
CHICAGO IL
60611-2927
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2929
  • Fax: 312-926-3595
Mailing address:
  • Phone: 312-926-2929
  • Fax: 312-926-3595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number40497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: