Provider Demographics
NPI:1164400974
Name:RICHIE, STEPHEN N (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:N
Last Name:RICHIE
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 1:107 VALLEY RUN DR
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-2428
Mailing Address - Country:US
Mailing Address - Phone:770-537-4446
Mailing Address - Fax:770-537-0484
Practice Address - Street 1:107 VALLEY RUN DR
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2428
Practice Address - Country:US
Practice Address - Phone:770-537-4446
Practice Address - Fax:770-537-0484
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008145122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00047649AMedicaid