Provider Demographics
NPI:1730505777
Name:TOM, ADELINE (DDS)
Entity type:Individual
Prefix:DR
First Name:ADELINE
Middle Name:
Last Name:TOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6795 CARNELIAN ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4556
Mailing Address - Country:US
Mailing Address - Phone:909-483-3431
Mailing Address - Fax:909-483-2052
Practice Address - Street 1:6795 CARNELIAN ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701-4556
Practice Address - Country:US
Practice Address - Phone:909-483-3431
Practice Address - Fax:909-483-2052
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist