Provider Demographics
NPI:1205907581
Name:FONNER, THOMAS W (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:FONNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GREENVIEW DR STE B
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3048
Mailing Address - Country:US
Mailing Address - Phone:217-540-5348
Mailing Address - Fax:217-540-5360
Practice Address - Street 1:100 GREENVIEW DR STE B
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3048
Practice Address - Country:US
Practice Address - Phone:217-540-5348
Practice Address - Fax:217-540-5360
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0249421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1014426Medicaid
IL1014426Medicaid