=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306955612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CEPHAS V THOMASON III D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3623 CALVIN DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-327-6262
-----------------------------------------------------
Fax | 706-327-1250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3623 CALVIN DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-327-6262
-----------------------------------------------------
Fax | 706-327-1250
-----------------------------------------------------
=====================================================
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 | GA6924
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------