Provider Demographics
NPI:1457497653
Name:RICHARDSON, WAYNE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 SW HIGGINS
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-3606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:918 SW HIGGINS
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-3606
Practice Address - Country:US
Practice Address - Phone:406-721-3679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist