=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437506946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMPSON DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2016
-----------------------------------------------------
Last Update Date | 05/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 CAMPUS AVE
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-2606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-875-3622
-----------------------------------------------------
Fax | 910-875-0164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 CAMPUS AVE
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-2606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-875-3622
-----------------------------------------------------
Fax | 910-875-0164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK STEPHEN THOMPSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 910-875-3622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5462
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------