MEDICARE: THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5432	WA
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	10731	WA

General Provider Information

NPI Number	:	1447630116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS

Provider Business Mailing Address
First Line	:	5620 112TH ST E
Second Line	:	SUITE 255
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3206
Country	:	US
Telephone Number	:	253-256-4000
Fax Number	:	253-770-9638

Provider Business Practice Location Address
First Line	:	5620 112TH ST E
Second Line	:	SUITE 255
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3206
Country	:	US
Telephone Number	:	253-256-4000
Fax Number	:	253-770-9638

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. THOMAS HENRY
Credential	:	DDS
Telephone Number	:	253-256-4000

Provider Enumeration Date	:	06/08/2015
Last Update Date	:	06/08/2015

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