Provider Demographics
NPI:1770668162
Name:THACKER, RALPH WILLIAM JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:WILLIAM
Last Name:THACKER
Suffix:JR
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 1:222 MAIN ST.
Mailing Address - Street 2:P.O BOX 490
Mailing Address - City:LIVERMORE
Mailing Address - State:KY
Mailing Address - Zip Code:42352-0490
Mailing Address - Country:US
Mailing Address - Phone:270-278-2385
Mailing Address - Fax:270-278-5111
Practice Address - Street 1:222 MAIN ST.
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:KY
Practice Address - Zip Code:42352-0490
Practice Address - Country:US
Practice Address - Phone:270-278-2385
Practice Address - Fax:270-278-5111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056496Medicaid