Provider Demographics
NPI:1861094542
Name:KALEB C THOMPSON DMD PA III
Entity type:Organization
Organization Name:KALEB C THOMPSON DMD PA III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-335-4341
Mailing Address - Street 1:153 WORTH GUARD RD
Mailing Address - Street 2:
Mailing Address - City:COINJOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27923-9766
Mailing Address - Country:US
Mailing Address - Phone:252-335-4341
Mailing Address - Fax:
Practice Address - Street 1:153 WORTH GUARD RD
Practice Address - Street 2:
Practice Address - City:COINJOCK
Practice Address - State:NC
Practice Address - Zip Code:27923-9766
Practice Address - Country:US
Practice Address - Phone:252-335-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1174594543Medicaid