=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407215619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS MAXWELL THANEY D.D.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2016
-----------------------------------------------------
Last Update Date | 11/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 N MAIN ST
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-637-6884
-----------------------------------------------------
Fax | 585-637-7087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 N MAIN ST
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-637-6884
-----------------------------------------------------
Fax | 585-637-7087
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OWNER/DENTIST
-----------------------------------------------------
Name | DR. THOMAS MAXWELL THANEY
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 585-637-6884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 051292
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------