Provider Demographics
NPI:1417219734
Name:THOMPSON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2852
Mailing Address - Country:US
Mailing Address - Phone:859-431-3254
Mailing Address - Fax:859-431-3255
Practice Address - Street 1:189 BAKER AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-3732
Practice Address - Country:US
Practice Address - Phone:314-961-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY94291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice