Provider Demographics
NPI:1124264965
Name:DR. KENNETH THOMPSON D.D.S.
Entity type:Organization
Organization Name:DR. KENNETH THOMPSON D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-273-5345
Mailing Address - Street 1:2701 SE G ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3740
Mailing Address - Country:US
Mailing Address - Phone:479-273-5345
Mailing Address - Fax:479-273-5335
Practice Address - Street 1:2701 SE G ST
Practice Address - Street 2:SUITE 9
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3740
Practice Address - Country:US
Practice Address - Phone:479-273-5345
Practice Address - Fax:479-273-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1888261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101101608Medicaid
AR1437286861OtherNPI TYPE 1