Basic Information
| Provider Information | |||||||||
| NPI: | 1194710947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DSS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 698 | ||||||||
| Address2: | 12 EAST BRUNSWICK | ||||||||
| City: | BYHALIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386110698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628382163 | ||||||||
| FaxNumber: | 6628387945 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 EAST BRUNSWICK | ||||||||
| Address2: | |||||||||
| City: | BYHALIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386110698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628382163 | ||||||||
| FaxNumber: | 6628387945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3569-10 | MS | Y | Dental Providers | Dentist | General Practice | 122300000X | 4742 | TN | N | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 00108254 | 05 | MS | MEDICAID | 3226520 | 05 | TN | MEDICAID |