Healthcare Provider Details

I. General information

NPI: 1164513248
Provider Name (Legal Business Name): MARK THOMPSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 W 10TH ST
INDIANAPOLIS IN
46234-2132
US

IV. Provider business mailing address

8930 W 10TH ST
INDIANAPOLIS IN
46234-2132
US

V. Phone/Fax

Practice location:
  • Phone: 317-271-6060
  • Fax: 317-271-6065
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7672
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: