Provider Demographics
NPI:1578922191
Name:THOMPSON, TRAVIS A (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:A
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E 10TH ST STE 106
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5771
Mailing Address - Country:US
Mailing Address - Phone:256-741-7340
Mailing Address - Fax:256-741-7373
Practice Address - Street 1:3439 B MCGEHEE ROAD, SUITE 22
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111
Practice Address - Country:US
Practice Address - Phone:334-288-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL6320.C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program