Healthcare Provider Details

I. General information

NPI: 1962467266
Provider Name (Legal Business Name): BRUCE HOWARD THOMPSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 BRAVE RIFLES REGIMENT ROAD HQS US ARMY DENTAL ACTIVITY
FORT KNOX KY
40121
US

IV. Provider business mailing address

223 VILLA RAY DR
RADCLIFF KY
40160-9290
US

V. Phone/Fax

Practice location:
  • Phone: 502-624-9670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6969
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: