=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528201787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYE ALAN THOMPSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2009
-----------------------------------------------------
Last Update Date | 08/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 W WALL ST
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79701-6523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-687-0629
-----------------------------------------------------
Fax | 432-687-3212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 W WALL ST
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79701-6523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-687-0629
-----------------------------------------------------
Fax | 432-687-3212
-----------------------------------------------------
=====================================================
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 | D7659
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 29882
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------