Healthcare Provider Details

I. General information

NPI: 1992970503
Provider Name (Legal Business Name): GEFFREY W. THOMPSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 W KATHLEEN AVE
COEUR D ALENE ID
83815-7365
US

IV. Provider business mailing address

1322 W KATHLEEN AVE
COEUR D ALENE ID
83815-7365
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-7461
  • Fax: 208-765-5753
Mailing address:
  • Phone: 208-667-7461
  • Fax: 208-765-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-1655
License Number StateID

VIII. Authorized Official

Name: DR. GEFFREY W. THOMPSON
Title or Position: OWNER
Credential: D.M.D.
Phone: 208-667-7461