Provider Demographics
NPI:1679313084
Name:THOMAS, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 CHESTER LN
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-4212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:938 CHESTER LN
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-4212
Practice Address - Country:US
Practice Address - Phone:801-995-5386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.004785122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist