Provider Demographics
NPI:1003897273
Name:THOMPSON, GARY M (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 BOONE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:KY
Mailing Address - Zip Code:40380-9435
Mailing Address - Country:US
Mailing Address - Phone:606-663-2133
Mailing Address - Fax:606-663-0699
Practice Address - Street 1:131 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-2174
Practice Address - Country:US
Practice Address - Phone:606-663-2133
Practice Address - Fax:606-663-0699
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4730OtherDELTA DENTAL OF KENTUCKY
KYY945OtherBLUE CROSS-BLUE SHIELD
KY60044732Medicaid