Healthcare Provider Details

I. General information

NPI: 1477607455
Provider Name (Legal Business Name): RANDOLPH P THOMAS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RANDY THOMAS D.M.D.

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S CENTRAL AVE
CHURCH HILL TN
37642-3723
US

IV. Provider business mailing address

PO BOX 349
CHURCH HILL TN
37642-0349
US

V. Phone/Fax

Practice location:
  • Phone: 423-357-7111
  • Fax: 423-357-1991
Mailing address:
  • Phone: 423-357-7111
  • Fax: 423-357-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS003397
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: