Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 1223D0001X | GA |
NPI | 1326170663 |
---|---|
Provider Name | Mr. Jerry Lamar Thomas |
First Address | Lagrange, GA 30241-3656 |
Second Address | Lagrange, GA 30241-3656 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2007 |
Last Update Date | 08/07/2007 |