Provider Demographics
NPI:1568512242
Name:THOMPSON, LISA VALDENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:VALDENE
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 1:1450 MERCANTILE LN
Mailing Address - Street 2:SUITE 207A
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5376
Mailing Address - Country:US
Mailing Address - Phone:240-455-7484
Mailing Address - Fax:240-455-7476
Practice Address - Street 1:1450 MERCANTILE LN
Practice Address - Street 2:SUITE 207A
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5376
Practice Address - Country:US
Practice Address - Phone:240-455-7484
Practice Address - Fax:240-455-7476
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice