Provider Demographics
NPI:1689697237
Name:THOMPSON, KENNETH CLYDE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CLYDE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:203 W 20TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-1100
Mailing Address - Country:US
Mailing Address - Phone:903-577-9900
Mailing Address - Fax:903-577-9901
Practice Address - Street 1:203 W 20TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-1100
Practice Address - Country:US
Practice Address - Phone:903-577-9900
Practice Address - Fax:903-577-9901
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX202141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87D558OtherTEXAS BCBS ID NUMBER
TX20214OtherLICENSE NUMBER
TX90075488OtherALABAMA BCBS ID NUMBER
TX1387039OtherUNITED CONCORDIA ID
TX1387039OtherUNITED CONCORDIA ID