Provider Demographics
NPI:1144414004
Name:CORDERO, RICHARD (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:CORDERO
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 TILLEY DR
Mailing Address - Street 2:STE 102
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4450
Mailing Address - Country:US
Mailing Address - Phone:802-862-9196
Mailing Address - Fax:802-862-5769
Practice Address - Street 1:118 TILLEY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4450
Practice Address - Country:US
Practice Address - Phone:802-862-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT873261223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTFC3158993OtherDEA-DEPARTMENT OF JUSTICE