Healthcare Provider Details

I. General information

NPI: 1760247480
Provider Name (Legal Business Name): KALEB C THOMPSON DMD PA V
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 AINSLEY AVE
HERTFORD NC
27944-1400
US

IV. Provider business mailing address

408 E COLONIAL AVE
ELIZABETH CITY NC
27909-4363
US

V. Phone/Fax

Practice location:
  • Phone: 252-335-4341
  • Fax:
Mailing address:
  • Phone: 252-335-4341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KALEB C THOMPSON
Title or Position: OWNER
Credential: DMD
Phone: 248-513-0259