Provider Demographics
NPI:1306825583
Name:RICHARDSON, ROGER W (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 OAKBROOKE CIRCLE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MT. WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047
Mailing Address - Country:US
Mailing Address - Phone:502-538-0363
Mailing Address - Fax:502-538-0362
Practice Address - Street 1:185 OAKBROOKE CIRCLE
Practice Address - Street 2:SUITE 1
Practice Address - City:MT. WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047
Practice Address - Country:US
Practice Address - Phone:502-538-0363
Practice Address - Fax:502-538-0362
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58621223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice