Provider Demographics
NPI:1083628796
Name:THOMPSON, KELLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:THOMOPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:6226 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6226 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4728
Practice Address - Country:US
Practice Address - Phone:501-562-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR114556608Medicaid