Provider Demographics
NPI:1114782836
Name:KALEB C THOMPSON DMD PA VI
Entity Type:Organization
Organization Name:KALEB C THOMPSON DMD PA VI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWHNER
Authorized Official - Prefix:
Authorized Official - First Name:KALEB
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:252-335-4341
Mailing Address - Street 1:814 CANAL COVE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-1816
Mailing Address - Country:US
Mailing Address - Phone:248-513-0259
Mailing Address - Fax:
Practice Address - Street 1:1006 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-6448
Practice Address - Country:US
Practice Address - Phone:252-335-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty