Provider Demographics
NPI:1154812881
Name:RAZDOLSKY, RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RAZDOLSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N VAN BUREN ST APT 1207
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3860
Mailing Address - Country:US
Mailing Address - Phone:847-980-6570
Mailing Address - Fax:
Practice Address - Street 1:135 CAPITOL DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2401
Practice Address - Country:US
Practice Address - Phone:262-691-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001915-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty