Provider Demographics
NPI:1487863593
Name:RICHARDSON, JACK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
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 1:3633 CORTEZ RD W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3119
Mailing Address - Country:US
Mailing Address - Phone:941-753-5857
Mailing Address - Fax:941-753-6186
Practice Address - Street 1:3633 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3119
Practice Address - Country:US
Practice Address - Phone:941-753-5857
Practice Address - Fax:941-753-6186
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN41551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice