Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 013698 | MO |
NPI | 1033226543 |
---|---|
Provider Name | Dr. Larry Wilson Thomas |
First Address | Creve Coeur, MO 63141-7029 |
Second Address | Creve Coeur, MO 63141-7029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 08/07/2007 |