MEDICARE: DR. LISA VALDENE THOMPSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	13668	MD

General Provider Information

NPI Number	:	1568512242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA VALDENE THOMPSON DDS

Provider Business Mailing Address
First Line	:	1450 MERCANTILE LN
Second Line	:	SUITE 207A
City	:	LARGO
State	:	MD
Zip	:	20774-5376
Country	:	US
Telephone Number	:	240-455-7484
Fax Number	:	240-455-7476

Provider Business Practice Location Address
First Line	:	1450 MERCANTILE LN
Second Line	:	SUITE 207A
City	:	LARGO
State	:	MD
Zip	:	20774-5376
Country	:	US
Telephone Number	:	240-455-7484
Fax Number	:	240-455-7476

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	03/09/2009

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