Provider Demographics
NPI:1053510255
Name:THOMAS, BROCK ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:ANTHONY
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 1:4737 SONOMA HWY STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-4267
Mailing Address - Country:US
Mailing Address - Phone:707-539-6777
Mailing Address - Fax:707-539-7501
Practice Address - Street 1:4737 SONOMA HWY STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-4267
Practice Address - Country:US
Practice Address - Phone:707-539-6777
Practice Address - Fax:707-539-7501
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA351751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice