Provider Demographics
NPI:1902928732
Name:THOMPSON, NATHAN F (DMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:F
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:502-774-8631
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:30 W MCCLAIN AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1847
Practice Address - Country:US
Practice Address - Phone:812-752-4428
Practice Address - Fax:812-752-7887
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74121223G0001X
IN120122181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100331880Medicaid