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General NPI Number Information
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NPI Number | 1760611875
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Entity Type | Individual
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Provider Name | DERRICK LANE THOMPSON DDS
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Gender | Male
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Dates
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Enumeration Date | 07/09/2009
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Last Update Date | 07/09/2009
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Provider Practice Location Address
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Address Line | 11645 WILSHIRE BLVD 703
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City | LOS ANGELES
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State | CA
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Zip | 90025-1708
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Country | US
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Telephone | 310-479-4432
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Fax | 310-477-5283
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Provider Business Mailing Address
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Address Line | 8117 W MANCHESTER AVE 387
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City | PLAYA DEL REY
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State | CA
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Zip | 90293-8745
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Country | US
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Telephone | 310-479-4432
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Fax | 310-477-8253
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 40893
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License Number State | CA
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