Provider Demographics
NPI:1710266416
Name:THOMPSON, SHANI O (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANI
Middle Name:O
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 1:700 24TH ST BLDG 8130
Mailing Address - Street 2:
Mailing Address - City:FORT GREGG ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9600
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT GREGG ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:786-210-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8059623-9921122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist