Provider Demographics
NPI:1518981844
Name:RICHARDSON, ESAIAS STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ESAIAS
Middle Name:STEVEN
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 1:1800 F S HILL DR
Mailing Address - Street 2:STE A
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5048
Mailing Address - Country:US
Mailing Address - Phone:662-226-1757
Mailing Address - Fax:662-307-2709
Practice Address - Street 1:1800 F S HILL DR
Practice Address - Street 2:STE A
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5048
Practice Address - Country:US
Practice Address - Phone:662-226-1757
Practice Address - Fax:662-307-2709
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3275-031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01078012Medicaid
MS20-1728874OtherEMPLOYER IDENTIFIER NUMBE