Healthcare Provider Details

I. General information

NPI: 1356405864
Provider Name (Legal Business Name): SCOTT DOUGLAS THOMPSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 BROAD ST
STORY CITY IA
50248-1564
US

IV. Provider business mailing address

1461 BROAD ST P.O. BOX 126
STORY CITY IA
50248-1564
US

V. Phone/Fax

Practice location:
  • Phone: 515-733-4441
  • Fax: 515-733-2407
Mailing address:
  • Phone: 515-733-4441
  • Fax: 515-733-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number08151
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: