Provider Demographics
NPI:1730745456
Name:THOMAS, MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:THOMAS
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 1:1838 N 1500 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5750
Mailing Address - Country:US
Mailing Address - Phone:909-631-6501
Mailing Address - Fax:
Practice Address - Street 1:4775 W DAYBREAK PKWY STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-5140
Practice Address - Country:US
Practice Address - Phone:801-280-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11276187-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice