Provider Demographics
NPI:1790368561
Name:THOMPSON, TERRY W
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:W
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 AVENUE F SW
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-6121
Mailing Address - Country:US
Mailing Address - Phone:703-651-6019
Mailing Address - Fax:
Practice Address - Street 1:907 AVENUE F SW
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201-6121
Practice Address - Country:US
Practice Address - Phone:703-651-6019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41843981126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86-1703082Medicaid