Provider Demographics
NPI:1225019748
Name:THOMPSON, THOMAS M (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
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 1:1848 LYDA AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3361
Mailing Address - Country:US
Mailing Address - Phone:270-783-0064
Mailing Address - Fax:270-901-1997
Practice Address - Street 1:1848 LYDA AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3361
Practice Address - Country:US
Practice Address - Phone:270-783-0064
Practice Address - Fax:270-901-1997
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57541223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000841Medicaid
KY60000841Medicaid