Provider Demographics
NPI:1194710947
Name:THOMPSON, DWIGHT (DSS)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 698
Mailing Address - Street 2:12 EAST BRUNSWICK
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611-0698
Mailing Address - Country:US
Mailing Address - Phone:662-838-2163
Mailing Address - Fax:662-838-7945
Practice Address - Street 1:12 EAST BRUNSWICK
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611-0698
Practice Address - Country:US
Practice Address - Phone:662-838-2163
Practice Address - Fax:662-838-7945
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3569-101223G0001X
TN4742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00108254Medicaid
TN3226520Medicaid
TN3226520Medicaid
TN3226520Medicare ID - Type Unspecified