Provider Demographics
NPI:1659482610
Name:THOMPSON, ELICIA NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELICIA
Middle Name:NICOLE
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 1:843 MILLING AVE
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-4442
Mailing Address - Country:US
Mailing Address - Phone:985-785-5800
Mailing Address - Fax:985-785-5811
Practice Address - Street 1:843 MILLING AVE
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4442
Practice Address - Country:US
Practice Address - Phone:985-785-5800
Practice Address - Fax:985-785-5811
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA58581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1858587Medicaid
LA1858587Medicaid
LA4K739CD42Medicare PIN