MEDICARE: DR. CORY GRANT THOMPSON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D8066	AZ
2	1223G0001X	General Practice Dentistry	DD3462	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881909893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORY GRANT THOMPSON D.M.D.

Provider Business Mailing Address
First Line	:	3015 HILLRISE DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4703
Country	:	US
Telephone Number	:	575-522-0454
Fax Number	:	575-522-3472

Provider Business Practice Location Address
First Line	:	3015 HILLRISE DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4703
Country	:	US
Telephone Number	:	575-522-0454
Fax Number	:	575-522-3472

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	02/04/2014

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