Provider Demographics
NPI:1487871356
Name:DANIELS, THOMAS ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALAN
Last Name:DANIELS
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 1:13341 N 2150TH AVE
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-9117
Mailing Address - Country:US
Mailing Address - Phone:309-944-3262
Mailing Address - Fax:
Practice Address - Street 1:216 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1402
Practice Address - Country:US
Practice Address - Phone:309-944-6125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice