=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306177357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH WILSON THOMPSON JR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2010
-----------------------------------------------------
Last Update Date | 01/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 BROOK AVE.
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-447-3309
-----------------------------------------------------
Fax | 434-447-8801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 BROOK AVE. P O BOX 455
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-447-3309
-----------------------------------------------------
Fax | 434-447-8801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5216
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------