Provider Demographics
NPI:1265451660
Name:FOSSUM, RICHARD F (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:F
Last Name:FOSSUM
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 1:2534 BLUE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7924
Mailing Address - Country:US
Mailing Address - Phone:254-778-3900
Mailing Address - Fax:253-681-0728
Practice Address - Street 1:2534 BLUE MEADOW DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-7924
Practice Address - Country:US
Practice Address - Phone:254-778-3900
Practice Address - Fax:253-681-0728
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX196391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice