Provider Demographics
NPI:1235725367
Name:THOMPSON, LOURDES
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 W GROVELEAF AVE
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-3930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41324 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-5111
Practice Address - Country:US
Practice Address - Phone:727-942-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty