Healthcare Provider Details

I. General information

NPI: 1780772962
Provider Name (Legal Business Name): MICHAEL L. THOMPSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 PAULA DR
JONESBORO AR
72404-8017
US

IV. Provider business mailing address

2737 PAULA DR
JONESBORO AR
72404-8017
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-0015
  • Fax: 870-932-0015
Mailing address:
  • Phone: 870-932-0015
  • Fax: 870-932-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2828
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: