Provider Demographics
NPI:1073629523
Name:GEORGE, RICHARD H (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:H
Last Name:GEORGE
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 1:527 RIGBY LAKE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1271
Mailing Address - Country:US
Mailing Address - Phone:208-745-8704
Mailing Address - Fax:208-745-7052
Practice Address - Street 1:527 RIGBY LAKE DR
Practice Address - Street 2:SUITE B
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1271
Practice Address - Country:US
Practice Address - Phone:208-745-8704
Practice Address - Fax:208-745-7052
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID69054OtherBLUE CROSS OF IDAHO