Provider Demographics
NPI:1376680561
Name:STRUB, RICHARD
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:STRUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14907 E PINNACLE CT
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-3333
Mailing Address - Country:US
Mailing Address - Phone:480-834-1555
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1161 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8823
Practice Address - Country:US
Practice Address - Phone:480-834-1555
Practice Address - Fax:480-962-6710
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD5530Medicaid