Provider Demographics
NPI:1689074783
Name:READEL, THOMAS JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:READEL
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 1:508 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76164-9157
Mailing Address - Country:US
Mailing Address - Phone:817-625-0341
Mailing Address - Fax:
Practice Address - Street 1:508 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-9157
Practice Address - Country:US
Practice Address - Phone:817-625-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20677122300000X
TX372231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist