Provider Demographics
NPI:1730593971
Name:THOMAS D SLACK DDS PC
Entity type:Organization
Organization Name:THOMAS D SLACK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-392-8596
Mailing Address - Street 1:2504 E PIKES PEAK AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-6031
Mailing Address - Country:US
Mailing Address - Phone:719-392-8596
Mailing Address - Fax:719-392-8298
Practice Address - Street 1:2504 E PIKES PEAK AVE STE 301
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-6031
Practice Address - Country:US
Practice Address - Phone:719-392-8596
Practice Address - Fax:719-392-8298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty