Provider Demographics
NPI:1518953777
Name:RICHESON, JOHN G (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:RICHESON
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 1:745 NEW HIGHWAY 68
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1913
Mailing Address - Country:US
Mailing Address - Phone:423-337-2034
Mailing Address - Fax:423-337-2036
Practice Address - Street 1:745 NEW HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874
Practice Address - Country:US
Practice Address - Phone:423-337-2034
Practice Address - Fax:423-337-2036
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS48301223G0001X
GADN0123051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA182916060AMedicaid
MO1518953777Medicaid