Healthcare Provider Details

I. General information

NPI: 1861677841
Provider Name (Legal Business Name): MICHAEL EDWARD THOMPSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MAPLECREST RD
FORT WAYNE IN
46815-7015
US

IV. Provider business mailing address

2801 MAPLECREST RD
FORT WAYNE IN
46815-7015
US

V. Phone/Fax

Practice location:
  • Phone: 260-485-2000
  • Fax: 260-486-8600
Mailing address:
  • Phone: 260-485-2000
  • Fax: 260-486-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1200871
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: