Provider Demographics
NPI:1013968528
Name:THOMPSON, BART DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:BART
Middle Name:DAVID
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 1:2707 LOUANNA ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4455
Mailing Address - Country:US
Mailing Address - Phone:989-835-5261
Mailing Address - Fax:989-832-2114
Practice Address - Street 1:2707 LOUANNA ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4455
Practice Address - Country:US
Practice Address - Phone:989-835-5261
Practice Address - Fax:989-832-2114
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010144701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI17559410051Medicaid