Provider Demographics
NPI:1255480406
Name:RICHARDSON, JOHN VERNON DALE (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:VERNON DALE
Last Name:RICHARDSON
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 1:1409 WHITLEY AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CORCORAN
Mailing Address - State:CA
Mailing Address - Zip Code:93212
Mailing Address - Country:US
Mailing Address - Phone:559-992-4138
Mailing Address - Fax:559-992-4079
Practice Address - Street 1:1409 WHITLEY AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212
Practice Address - Country:US
Practice Address - Phone:559-992-4138
Practice Address - Fax:559-992-4079
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice