Provider Demographics
NPI:1982822904
Name:THOMPSON, DEREK C (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:C
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-1577
Mailing Address - Country:US
Mailing Address - Phone:509-457-6300
Mailing Address - Fax:509-248-7438
Practice Address - Street 1:2100 S 14TH ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1252
Practice Address - Country:US
Practice Address - Phone:509-457-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA721548754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5038799Medicaid