Provider Demographics
NPI:1336461094
Name:DAMON B THOMPSON DDS PC
Entity Type:Organization
Organization Name:DAMON B THOMPSON DDS PC
Other - Org Name:REAL LIFE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:B
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:540-552-5433
Mailing Address - Street 1:202 S MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-4880
Mailing Address - Country:US
Mailing Address - Phone:540-552-5433
Mailing Address - Fax:540-552-2273
Practice Address - Street 1:202 S MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-4880
Practice Address - Country:US
Practice Address - Phone:540-552-5433
Practice Address - Fax:540-552-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178608Medicaid