Provider Demographics
NPI:1407860810
Name:RICHARDSON, PHILLIP DAVID (RDH, DOM)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:DAVID
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:RDH, DOM
Other - Prefix:DR
Other - First Name:PHILLIP
Other - Middle Name:DAVID
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH, DOM
Mailing Address - Street 1:717 ENCINO PLACE NE SUITE 7
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102
Mailing Address - Country:US
Mailing Address - Phone:505-843-9636
Mailing Address - Fax:505-843-6277
Practice Address - Street 1:717 ENCINO PLACE NE SUITE 7
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-843-9636
Practice Address - Fax:505-843-6277
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOORJ13OtherBLUE CROSS BLUE SHIELD