Provider Demographics
NPI:1982161501
Name:THOMPSON, SAMUEL MICHAEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MICHAEL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4868 BRIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4654
Mailing Address - Country:US
Mailing Address - Phone:270-925-8190
Mailing Address - Fax:
Practice Address - Street 1:DENTAL COLLEGE OF GEORGIA 1120 15TH STREET GC 5110
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-721-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program