Provider Demographics
NPI:1861601635
Name:DERIENZO, THOMAS LOUIS (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LOUIS
Last Name:DERIENZO
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 1:15 CORNERSTONE CT UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1550
Mailing Address - Country:US
Mailing Address - Phone:860-621-2700
Mailing Address - Fax:
Practice Address - Street 1:15 CORNERSTONE CT UNIT 1
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1550
Practice Address - Country:US
Practice Address - Phone:860-621-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7271122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist