Provider Demographics
NPI:1306177357
Name:THOMPSON, KENNETH WILSON JR (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILSON
Last Name:THOMPSON
Suffix:JR
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 1:107 BROOK AVE.
Mailing Address - Street 2:P O BOX 455
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970
Mailing Address - Country:US
Mailing Address - Phone:434-447-3309
Mailing Address - Fax:434-447-8801
Practice Address - Street 1:107 BROOK AVE.
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970
Practice Address - Country:US
Practice Address - Phone:434-447-3309
Practice Address - Fax:434-447-8801
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA52161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice