Provider Demographics
NPI:1144392150
Name:RICHMOND, MARY JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JEAN
Last Name:RICHMOND
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 1:521 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4719
Mailing Address - Country:US
Mailing Address - Phone:209-823-9218
Mailing Address - Fax:209-823-1134
Practice Address - Street 1:521 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4719
Practice Address - Country:US
Practice Address - Phone:209-823-9218
Practice Address - Fax:209-823-1134
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA359801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice