Provider Demographics
NPI:1417323817
Name:THOMPSON, CRYSTAL (DDS)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 ELLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8216
Mailing Address - Country:US
Mailing Address - Phone:541-779-9059
Mailing Address - Fax:541-779-0226
Practice Address - Street 1:940 ELLENDALE DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8216
Practice Address - Country:US
Practice Address - Phone:541-779-9059
Practice Address - Fax:541-779-0226
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD102981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice