Provider Demographics
NPI:1376715425
Name:MERCADO RICHARDSON, JORGE L (DMD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:MERCADO RICHARDSON
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 1:1315 E ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-2117
Mailing Address - Country:US
Mailing Address - Phone:407-896-5656
Mailing Address - Fax:407-897-6797
Practice Address - Street 1:1315 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-2117
Practice Address - Country:US
Practice Address - Phone:407-896-5656
Practice Address - Fax:407-897-6797
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187811223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program