Provider Demographics
NPI:1184775660
Name:BACON, THOMAS RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAYMOND
Last Name:BACON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 KINGSFORD RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-2210
Mailing Address - Country:US
Mailing Address - Phone:603-643-6013
Mailing Address - Fax:603-542-3531
Practice Address - Street 1:200 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-2685
Practice Address - Country:US
Practice Address - Phone:603-542-5197
Practice Address - Fax:603-542-3531
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice