Provider Demographics
NPI:1689788598
Name:THOMPSON, KENNETH D (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
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 1:4213 DALE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8505
Mailing Address - Country:US
Mailing Address - Phone:209-545-4760
Mailing Address - Fax:209-545-2166
Practice Address - Street 1:4213 DALE RD.
Practice Address - Street 2:SUITE 5
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356
Practice Address - Country:US
Practice Address - Phone:209-545-4760
Practice Address - Fax:209-545-2166
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice