Provider Demographics
NPI:1538289855
Name:RICHARDSON, ROY WYATT III (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:WYATT
Last Name:RICHARDSON
Suffix:III
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 1:1276 STAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3286
Mailing Address - Country:US
Mailing Address - Phone:704-289-4505
Mailing Address - Fax:704-283-8654
Practice Address - Street 1:1276 STAFFORD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3286
Practice Address - Country:US
Practice Address - Phone:704-289-4505
Practice Address - Fax:704-283-8654
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997374Medicaid