Basic Information
| Provider Information | |||||||||
| NPI: | 1467717272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | JACKSON | ||||||||
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| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16505 NW 205TH ST | ||||||||
| Address2: | |||||||||
| City: | HIGH SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326438168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863446543 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867547259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2012 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN19968 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DN19968 | 01 | FL | STATE LICENSE | OTHER |