Provider Demographics
NPI:1568702769
Name:THOMPSON, ROBERT R (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
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 1:2100 HUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-4424
Mailing Address - Country:US
Mailing Address - Phone:505-327-1186
Mailing Address - Fax:505-327-6103
Practice Address - Street 1:2100 HUTTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4424
Practice Address - Country:US
Practice Address - Phone:505-327-1186
Practice Address - Fax:505-327-6103
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
201950784OtherTIN