=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326588039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERIDA R. THOMAS DENTAL HYGIENIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1061 HARMON AVE ATTN: CREDENTIALS OFFICE,US ARMY DENTAL HEALTH ACTIVITY
-----------------------------------------------------
City | FORT STEWART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31314-5641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-435-7006
-----------------------------------------------------
Fax | 912-435-7042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1061 HARMON AVE US ARMY DENTAL HEALTH ACTIVITY
-----------------------------------------------------
City | FORT STEWART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31314-5641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-435-7006
-----------------------------------------------------
Fax | 912-435-7042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH011640
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------