Healthcare Provider Details

I. General information

NPI: 1336293174
Provider Name (Legal Business Name): TEJJY THOMAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S 16TH ST SUITE 900
PHILADELPHIA PA
19102-3322
US

IV. Provider business mailing address

1801 BUTTONWOOD ST SUITE 1507
PHILADELPHIA PA
19130-3945
US

V. Phone/Fax

Practice location:
  • Phone: 215-545-2600
  • Fax:
Mailing address:
  • Phone: 215-805-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number036917
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS036917
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: