Basic Information
| Provider Information | |||||||||
| NPI: | 1346463478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOMKIE | ||||||||
| FirstName: | GERARD | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80B VETERANS BLVD | ||||||||
| Address2: | ACOMA-CANONCITO-LAGUNA INDIAN | ||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80B VETERANS BLVD | ||||||||
| Address2: | ACOMA-CANONCITO-LAGUNA INDIAN | ||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 11138 | MI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | H3451 | 05 | NM | MEDICAID |