Provider Demographics
NPI:1538469820
Name:THOMPSON, KACEY-ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KACEY-ANN
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 1:128 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2634
Mailing Address - Country:US
Mailing Address - Phone:914-668-2772
Mailing Address - Fax:914-668-2657
Practice Address - Street 1:128 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2634
Practice Address - Country:US
Practice Address - Phone:914-668-2772
Practice Address - Fax:914-668-2657
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6628-15122300000X
NY0565421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1538469820Medicaid
WI390200000XMedicaid