Provider Demographics
NPI:1417939174
Name:THOMPSON, MICHAEL DAVID (DDS, FAGD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 AMAZONAS DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5717
Mailing Address - Country:US
Mailing Address - Phone:573-634-2400
Mailing Address - Fax:573-761-7528
Practice Address - Street 1:3551 AMAZONAS DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5717
Practice Address - Country:US
Practice Address - Phone:573-634-2400
Practice Address - Fax:573-761-7528
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0114941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
7319030001Medicare NSC