=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063825990
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS RYAN MCPHERSON D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2014
-----------------------------------------------------
Last Update Date | 07/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 FAIRPOINT DR STE A
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-934-2820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 FAIRPOINT DR STE A
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32561-4380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-934-2820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN20589
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------