Provider Demographics
NPI:1053866335
Name:RICHARDSON, UGENDIESIDETT
Entity Type:Individual
Prefix:MRS
First Name:UGENDIESIDETT
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SIDETT
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:45524 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-4211
Mailing Address - Country:US
Mailing Address - Phone:803-917-2597
Mailing Address - Fax:
Practice Address - Street 1:45524 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-4211
Practice Address - Country:US
Practice Address - Phone:803-917-2597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85738126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant