MEDICARE: LISA V. THOMPSON, DDS, LLC

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	261QD0000X	Dental Clinic/Center	13668	MD

General Provider Information

NPI Number	:	1922249200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA V. THOMPSON, DDS, LLC

Provider Business Mailing Address
First Line	:	1450 MERCANTILE LN
Second Line	:	SUITE 207A
City	:	LARGO
State	:	MD
Zip	:	20774-5376
Country	:	US
Telephone Number	:	204-455-7484
Fax Number	:	240-455-7476

Provider Business Practice Location Address
First Line	:	1450 MERCANTILE LN
Second Line	:	SUITE 207A
City	:	LARGO
State	:	MD
Zip	:	20774-5376
Country	:	US
Telephone Number	:	204-455-7484
Fax Number	:	240-455-7476

Authorized Official
Title or Position	:	CEO, OWNER
Name	:	DR. LISA VALDENE THOMPSON
Credential	:	DDS
Telephone Number	:	240-455-7484

Provider Enumeration Date	:	03/16/2009
Last Update Date	:	03/16/2009

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