Provider Demographics
NPI:1417198409
Name:RICHARD F. FOSSUM DDS, PA
Entity Type:Organization
Organization Name:RICHARD F. FOSSUM DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-778-3900
Mailing Address - Street 1:2534 BLUE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7924
Mailing Address - Country:US
Mailing Address - Phone:254-778-3900
Mailing Address - Fax:
Practice Address - Street 1:2534 BLUE MEADOW DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-7924
Practice Address - Country:US
Practice Address - Phone:254-778-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-20
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty