Provider Demographics
NPI:1730576752
Name:THOMAS A CLOSURDO JR DDS PC
Entity type:Organization
Organization Name:THOMAS A CLOSURDO JR DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLOSURDO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-288-1900
Mailing Address - Street 1:211 N SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2823
Mailing Address - Country:US
Mailing Address - Phone:574-288-1900
Mailing Address - Fax:
Practice Address - Street 1:211 N SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2823
Practice Address - Country:US
Practice Address - Phone:574-288-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120119461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201200360Medicaid