Provider Demographics
NPI:1447630116
Name:THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS
Entity type:Organization
Organization Name:THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-256-4000
Mailing Address - Street 1:5620 112TH ST E
Mailing Address - Street 2:SUITE 255
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3206
Mailing Address - Country:US
Mailing Address - Phone:253-256-4000
Mailing Address - Fax:253-770-9638
Practice Address - Street 1:5620 112TH ST E
Practice Address - Street 2:SUITE 255
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3206
Practice Address - Country:US
Practice Address - Phone:253-256-4000
Practice Address - Fax:253-770-9638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5432122300000X
WA107311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty