Provider Demographics
NPI:1528229416
Name:RICHARDSON, KELLY DIANE (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LINDEN DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2894
Mailing Address - Country:US
Mailing Address - Phone:337-493-5163
Mailing Address - Fax:337-439-5866
Practice Address - Street 1:212 LINDEN DR
Practice Address - Street 2:SUITE 150
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2894
Practice Address - Country:US
Practice Address - Phone:337-493-5163
Practice Address - Fax:337-439-5866
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60563122300000X
LA6038122300000X
VA0401412717122300000X
TX27594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100456320QMedicaid
LA1860387Medicaid