Provider Demographics
NPI:1871696203
Name:GOTSIS, THOMAS MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:GOTSIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12266 DEPAUL DR
Mailing Address - Street 2:STE 325
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-291-9000
Mailing Address - Fax:314-291-0590
Practice Address - Street 1:12266 DEPAUL DR
Practice Address - Street 2:STE 325
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-291-9000
Practice Address - Fax:314-291-0590
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0154761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
6473770001OtherPTAN