Provider Demographics
NPI:1225779663
Name:RICHARDS, JACQUELYN CAROLE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:CAROLE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 E DEDHAM ST PH 1111
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3562
Mailing Address - Country:US
Mailing Address - Phone:207-975-6068
Mailing Address - Fax:
Practice Address - Street 1:735 ATTUCKS LN
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-1867
Practice Address - Country:US
Practice Address - Phone:508-778-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL15250122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty