Provider Demographics
NPI:1255444295
Name:THOMPSON, PETER L (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:L
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 1:123 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6201
Mailing Address - Country:US
Mailing Address - Phone:505-359-1011
Mailing Address - Fax:505-356-2947
Practice Address - Street 1:123 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6201
Practice Address - Country:US
Practice Address - Phone:505-359-1011
Practice Address - Fax:505-356-2947
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD22671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice