Healthcare Provider Details

I. General information

NPI: 1295345270
Provider Name (Legal Business Name): SAMUEL LEE THOMAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PEACOCK COURT
SEYMOUR TN
37865
US

IV. Provider business mailing address

111 PEACOCK COURT
SEYMOUR TN
37865
US

V. Phone/Fax

Practice location:
  • Phone: 865-573-0274
  • Fax: 865-577-0174
Mailing address:
  • Phone: 865-573-0274
  • Fax: 865-577-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number11358
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: