Provider Demographics
NPI:1053360073
Name:PACKER, THOMAS MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:PACKER
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 1:24 SALT POND ROAD
Mailing Address - Street 2:SUITE F1
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4335
Mailing Address - Country:US
Mailing Address - Phone:401-788-8820
Mailing Address - Fax:401-788-9048
Practice Address - Street 1:24 SALT POND ROAD
Practice Address - Street 2:SUITE F1
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4335
Practice Address - Country:US
Practice Address - Phone:401-788-8820
Practice Address - Fax:401-788-9048
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI16941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1694OtherDELTA DENTAL
RI83496OtherBC DENTAL
RITP00819Medicaid