=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942287875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS J KING III DDS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2005
-----------------------------------------------------
Last Update Date | 02/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 BRYANT ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-557-1440
-----------------------------------------------------
Fax | 563-557-7001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 BRYANT ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-557-1440
-----------------------------------------------------
Fax | 563-557-7001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 47958
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 08393
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 5844015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D11448
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 019026707
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 36804
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 49434020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------