Provider Demographics
NPI:1326193657
Name:RICHARDSON, MARK E (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:RICHARDSON
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 1:1103 GAYLE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048
Mailing Address - Country:US
Mailing Address - Phone:269-343-6907
Mailing Address - Fax:269-343-2584
Practice Address - Street 1:1103 GAYLE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048
Practice Address - Country:US
Practice Address - Phone:269-343-6907
Practice Address - Fax:269-343-2584
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID16169122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist