=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043489255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS OLLERHEAD, DMD, CAGS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2008
-----------------------------------------------------
Last Update Date | 02/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 UNION ST 6
-----------------------------------------------------
City | MARLBOROUGH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01752-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-787-0070
-----------------------------------------------------
Fax | 508-787-0071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 UNION ST 6
-----------------------------------------------------
City | MARLBOROUGH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01752-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-787-0070
-----------------------------------------------------
Fax | 508-787-0071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. THOMAS R OLLERHEAD
-----------------------------------------------------
Credential | DMD, CAGS
-----------------------------------------------------
Telephone | 508-787-0070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------