Healthcare Provider Details

I. General information

NPI: 1871666065
Provider Name (Legal Business Name): THOMAS T TABACHNICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E LONGVIEW DR SUITE C
APPLETON WI
54911-2168
US

IV. Provider business mailing address

533 W OLD SLEIGH LN
APPLETON WI
54913-7174
US

V. Phone/Fax

Practice location:
  • Phone: 920-427-6465
  • Fax: 920-991-2517
Mailing address:
  • Phone: 920-427-6465
  • Fax: 920-991-2517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5000840015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: