Provider Demographics
NPI:1255674198
Name:DWAYNE F RICHARDSON DDS ESTATE
Entity Type:Organization
Organization Name:DWAYNE F RICHARDSON DDS ESTATE
Other - Org Name:RICHARDSON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-292-0722
Mailing Address - Street 1:17395 US HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-6162
Mailing Address - Country:US
Mailing Address - Phone:901-466-9833
Mailing Address - Fax:901-466-9834
Practice Address - Street 1:17395 US HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-6162
Practice Address - Country:US
Practice Address - Phone:901-466-9833
Practice Address - Fax:901-466-9834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty