Provider Demographics
NPI:1366474983
Name:CRIST, RICHARD TODD (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TODD
Last Name:CRIST
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 1:1340 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-3342
Mailing Address - Country:US
Mailing Address - Phone:270-825-0676
Mailing Address - Fax:270-825-0696
Practice Address - Street 1:1340 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-3342
Practice Address - Country:US
Practice Address - Phone:270-825-0676
Practice Address - Fax:270-825-0696
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81991223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003829Medicaid
KY122300000XMedicaid