Provider Demographics
NPI:1295013340
Name:RICHARDSON DENTAL AND ASSOCIATES
Entity Type:Organization
Organization Name:RICHARDSON DENTAL AND ASSOCIATES
Other - Org Name:MAGNOLIA FAMILY DENTISTRY OF COLUMBUS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-327-2002
Mailing Address - Street 1:1227 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2138
Mailing Address - Country:US
Mailing Address - Phone:662-327-2002
Mailing Address - Fax:366-232-7201
Practice Address - Street 1:1227 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2138
Practice Address - Country:US
Practice Address - Phone:662-327-2002
Practice Address - Fax:366-232-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3463-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS001989359OtherUNITED CONCORDIA
MS02150825Medicaid