Provider Demographics
NPI:1316790157
Name:THURSTON, LAYNE G
Entity type:Individual
Prefix:
First Name:LAYNE
Middle Name:G
Last Name:THURSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 BROMPTON ST APT 4821
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-2167
Mailing Address - Country:US
Mailing Address - Phone:607-651-3874
Mailing Address - Fax:
Practice Address - Street 1:5106 FAIRMONT PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3728
Practice Address - Country:US
Practice Address - Phone:607-651-3874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2025-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX414111223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program