Provider Demographics
NPI:1093772634
Name:RICHARDSON, BRENDA (DDS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4584
Mailing Address - Country:US
Mailing Address - Phone:315-464-2096
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:819 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3536
Practice Address - Country:US
Practice Address - Phone:315-476-7921
Practice Address - Fax:315-474-1448
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02218431Medicaid
NYU95641Medicare UPIN
NYJ400017604Medicare PIN