Provider Demographics
NPI:1053473926
Name:DERRICK, RICHARD E (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:DERRICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-1424
Mailing Address - Country:US
Mailing Address - Phone:973-543-6666
Mailing Address - Fax:973-543-5701
Practice Address - Street 1:3 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:MENDHAM
Practice Address - State:NJ
Practice Address - Zip Code:07945-1424
Practice Address - Country:US
Practice Address - Phone:973-543-6666
Practice Address - Fax:973-543-5701
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI00808700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist