Provider Demographics
NPI:1053810598
Name:THOMAS, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 POMERADO RD STE E4
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2427
Mailing Address - Country:US
Mailing Address - Phone:858-848-9660
Mailing Address - Fax:
Practice Address - Street 1:16767 BERNARDO CENTER DR STE L1 #27384
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-9212
Practice Address - Country:US
Practice Address - Phone:858-848-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25037124Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist