=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114089281
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS JOHN GILL D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 10TH AVE.
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-351-6611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 418 10TH AVE BOX 5125
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-351-6611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6585
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------