Provider Demographics
NPI:1053486134
Name:RICHARDSON, THOMAS BRYANT (DDS)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BRYANT
Last Name:RICHARDSON
Suffix:
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 1:1610 W C PL
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2705
Mailing Address - Country:US
Mailing Address - Phone:479-968-8338
Mailing Address - Fax:479-968-1688
Practice Address - Street 1:1610 W C PL
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2705
Practice Address - Country:US
Practice Address - Phone:479-968-8338
Practice Address - Fax:479-968-1688
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ150768608Medicaid
AR1593213OtherUNITED CONCORDIA PROV #
AR5X544OtherBLUE CROSS PROV #