Active NPI
Thomas Michael Mack, DDS
- General Practice Dentistry
- Glendale, AZ
National Provider Identifier
1659474013
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 3872
- Practice address
- 17215 N 72ND Dr
Ste A100
Glendale, AZ 85308 - Phone
- (623) 582-8384
- Fax
- (623) 582-1722
- NPI assigned
- Sep 7, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 3872 | AZ | Primary |
| General Practice Dentistry | 1223G0001X | 1682 | NM | |
| General Practice Dentistry | 1223G0001X | 3681 | SC |
Addresses
Primary practice location
17215 N 72ND Dr
Ste A100
Glendale, AZ 85308
Mailing address
17215 N 72ND Dr
Ste A100
Glendale, AZ 85308
Phone (623) 582-8384
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1682 | NM | MD | Occupational Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Souza DDS LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1157587200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1659474013",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "17215 N 72ND DR",
"address_2": "STE A100",
"city": "GLENDALE",
"state": "AZ",
"postal_code": "85308",
"telephone_number": "623-582-8384",
"fax_number": "623-582-1722"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "17215 N 72ND DR",
"address_2": "STE A100",
"city": "GLENDALE",
"state": "AZ",
"postal_code": "85308",
"telephone_number": "623-582-8384",
"fax_number": "623-582-1722"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MACK",
"first_name": "THOMAS",
"middle_name": "MICHAEL",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-09-07",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "AZ",
"license": "3872",
"primary": true
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NM",
"license": "1682",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "SC",
"license": "3681",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glendale, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.