Provider Demographics
NPI:1871656348
Name:THOMPSON, CAROLYN REBECCA (DMD)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:REBECCA
Last Name:THOMPSON
Suffix:
Gender:F
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:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135
Mailing Address - Country:US
Mailing Address - Phone:803-874-4500
Mailing Address - Fax:803-874-4502
Practice Address - Street 1:811 HARRY RAYSOR DRIVE
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135
Practice Address - Country:US
Practice Address - Phone:803-874-4500
Practice Address - Fax:803-874-4502
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ30878Medicaid