Provider Demographics
NPI:1326561093
Name:RICHARDSON, JEREMY (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
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:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-1146
Mailing Address - Country:US
Mailing Address - Phone:304-263-4999
Mailing Address - Fax:304-263-0984
Practice Address - Street 1:58 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-3800
Practice Address - Country:US
Practice Address - Phone:304-267-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice