Provider Demographics
NPI:1548482649
Name:THOMAS, IMAD K (DDS)
Entity type:Individual
Prefix:
First Name:IMAD
Middle Name:K
Last Name:THOMAS
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 1:26008 BROOKMERE AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3934
Mailing Address - Country:US
Mailing Address - Phone:949-439-3376
Mailing Address - Fax:
Practice Address - Street 1:3559 W RAMSEY ST
Practice Address - Street 2:C-1
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3505
Practice Address - Country:US
Practice Address - Phone:951-922-3993
Practice Address - Fax:951-922-3998
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA342331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330256700OtherTAX ID
CA330256700OtherTAX ID