Provider Demographics
NPI:1457414088
Name:THOMPSON, JOAN (DDS)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LOURDES DR
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-6709
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:888 WORCESTER ST
Practice Address - Street 2:SUITE 130
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-3744
Practice Address - Country:US
Practice Address - Phone:617-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1319833Medicaid