Provider Demographics
NPI:1588118756
Name:THOMPSON, KAITLYN MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:MARIE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 LIGHTHOUSE DR
Mailing Address - Street 2:UNIT 4126
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-6894
Mailing Address - Country:US
Mailing Address - Phone:941-840-8927
Mailing Address - Fax:
Practice Address - Street 1:1401 LIGHTHOUSE DR
Practice Address - Street 2:UNIT 4126
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-6894
Practice Address - Country:US
Practice Address - Phone:941-840-8927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD 8792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist