Provider Demographics
NPI:1497991863
Name:THOMPSON, JENNIFER L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
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 1:1212 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4215
Mailing Address - Country:US
Mailing Address - Phone:505-327-6233
Mailing Address - Fax:505-324-6442
Practice Address - Street 1:1212 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4215
Practice Address - Country:US
Practice Address - Phone:505-327-6233
Practice Address - Fax:505-324-6442
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3082122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice