Healthcare Provider Details

I. General information

NPI: 1558311894
Provider Name (Legal Business Name): JEFFERY RAYMOND THOMAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 VILLAGE WAY
TRENT WOODS NC
28562-7305
US

IV. Provider business mailing address

2808 VILLAGE WAY
TRENT WOODS NC
28562-7305
US

V. Phone/Fax

Practice location:
  • Phone: 252-633-1631
  • Fax: 252-633-3922
Mailing address:
  • Phone: 252-633-1631
  • Fax: 252-633-3922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberNC4542
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: