Provider Demographics
NPI:1477634574
Name:RICHARDSON, MICHAEL QUINCY ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:QUINCY ALAN
Last Name: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 1:4965 LANIER ISLANDS PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1717
Mailing Address - Country:US
Mailing Address - Phone:770-831-0559
Mailing Address - Fax:
Practice Address - Street 1:4965 LANIER ISLANDS PKWY STE 105
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1717
Practice Address - Country:US
Practice Address - Phone:770-831-0559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300220651223G0001X
GADN0147511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice