Provider Demographics
NPI:1265701205
Name:TOM, THOMPSON (DDS)
Entity type:Individual
Prefix:
First Name:THOMPSON
Middle Name:
Last Name:TOM
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 1:5990 STONERIDGE DR STE 115
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3234
Mailing Address - Country:US
Mailing Address - Phone:925-734-0748
Mailing Address - Fax:
Practice Address - Street 1:5990 STONERIDGE DR STE 115
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3234
Practice Address - Country:US
Practice Address - Phone:925-734-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA326231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics