Healthcare Provider Details

I. General information

NPI: 1134836315
Provider Name (Legal Business Name): MISTY THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 N 28TH ST APT 212
PHOENIX AZ
85016-6832
US

IV. Provider business mailing address

3851 N 28TH ST APT 212
PHOENIX AZ
85016-6832
US

V. Phone/Fax

Practice location:
  • Phone: 623-999-5643
  • Fax:
Mailing address:
  • Phone: 623-999-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: