Provider Demographics
NPI:1508907627
Name:THOMPSON, MARK STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 CAMPUS AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-2606
Mailing Address - Country:US
Mailing Address - Phone:910-875-3622
Mailing Address - Fax:910-875-3622
Practice Address - Street 1:114 CAMPUS AVE.
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2606
Practice Address - Country:US
Practice Address - Phone:910-875-3622
Practice Address - Fax:910-875-3622
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC54621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8998450Medicaid