Provider Demographics
NPI:1356405864
Name:THOMPSON, SCOTT DOUGLAS (DDS)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 BROAD ST
Mailing Address - Street 2:P.O. BOX 126
Mailing Address - City:STORY CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50248-1564
Mailing Address - Country:US
Mailing Address - Phone:515-733-4441
Mailing Address - Fax:515-733-2407
Practice Address - Street 1:1461 BROAD ST
Practice Address - Street 2:
Practice Address - City:STORY CITY
Practice Address - State:IA
Practice Address - Zip Code:50248-1564
Practice Address - Country:US
Practice Address - Phone:515-733-4441
Practice Address - Fax:515-733-2407
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0270470Medicaid