MEDICARE: DR. BLAINE RANDY THORN II DDS

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	1223G0001X	General Practice Dentistry	12079	TX

General Provider Information

NPI Number	:	1821073628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAINE RANDY THORN II DDS

Provider Business Mailing Address
First Line	:	2815 W LAKE HOUSTON PKWY
Second Line	:	SUITE110
City	:	HUMBLE
State	:	TX
Zip	:	77339-5227
Country	:	US
Telephone Number	:	281-360-5645
Fax Number	:	281-360-8439

Provider Business Practice Location Address
First Line	:	2815 W LAKE HOUSTON PKWY
Second Line	:	SUITE110
City	:	HUMBLE
State	:	TX
Zip	:	77339-5227
Country	:	US
Telephone Number	:	281-360-5645
Fax Number	:	281-360-8439

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/08/2007

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