Provider Demographics
NPI:1356072383
Name:THOMPSON, SOFIA (DMD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GREEN BAY RD APT 228
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3440 OHIO ST BLDG 1017
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-3155
Practice Address - Country:US
Practice Address - Phone:847-688-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0337821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice