=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033226543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY WILSON THOMAS D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11709 OLD BALLAS RD STE 200
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-872-8590
-----------------------------------------------------
Fax | 314-872-3523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11709 OLD BALLAS RD STE 200
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-872-8590
-----------------------------------------------------
Fax | 314-872-3523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 013698
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------