Healthcare Provider Details

I. General information

NPI: 1336339878
Provider Name (Legal Business Name): MICHELLE MARIE THOMPSON RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 N BRAND BLVD
GLENDALE CA
91222
US

IV. Provider business mailing address

1134 N BRAND BLVD
GLENDALE CA
91222
US

V. Phone/Fax

Practice location:
  • Phone: 818-246-2253
  • Fax:
Mailing address:
  • Phone: 818-246-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number59247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: