Provider Demographics
NPI:1043521131
Name:THOMAS, SUSAN TINA (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:TINA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E NORTH WATER ST
Mailing Address - Street 2:UNIT 3501
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-0815
Mailing Address - Country:US
Mailing Address - Phone:713-471-2654
Mailing Address - Fax:
Practice Address - Street 1:600 LACKAWANNA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-2046
Practice Address - Country:US
Practice Address - Phone:570-342-9136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0383461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice