Provider Demographics
NPI:1306232764
Name:RICHARDSPN DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:RICHARDSPN DENTAL PROFESSIONALS
Other - Org Name:RICHARDSON COSMETIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:MAXWELL
Authorized Official - Last Name:GOAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-690-6653
Mailing Address - Street 1:700 E CAMPBELL RD
Mailing Address - Street 2:STE. #240
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2041
Mailing Address - Country:US
Mailing Address - Phone:972-690-6653
Mailing Address - Fax:972-680-8757
Practice Address - Street 1:700 E CAMPBELL RD
Practice Address - Street 2:STE. #240
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2041
Practice Address - Country:US
Practice Address - Phone:972-690-6653
Practice Address - Fax:972-680-8757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11808305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization