Provider Demographics
NPI:1821488982
Name:THOMPSON, SAMANTHA (RDH)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1215
Mailing Address - Country:US
Mailing Address - Phone:719-251-5183
Mailing Address - Fax:
Practice Address - Street 1:1630 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1856
Practice Address - Country:US
Practice Address - Phone:719-545-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905515124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80354068Medicaid