Provider Demographics
NPI:1326120817
Name:RICHARDS, MARK WARREN (DDS,MED)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WARREN
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:DDS,MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MED CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506
Mailing Address - Country:US
Mailing Address - Phone:304-293-2240
Mailing Address - Fax:304-293-7646
Practice Address - Street 1:1 MED CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-2240
Practice Address - Fax:304-293-7646
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV32031223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics