Provider Demographics
NPI:1568599348
Name:RICHARDSON, BEVAN MILTON (DDS)
Entity Type:Individual
Prefix:PROF
First Name:BEVAN
Middle Name:MILTON
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 1:851 OAK LN
Mailing Address - Street 2:
Mailing Address - City:RIO LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:95673-2341
Mailing Address - Country:US
Mailing Address - Phone:916-991-6402
Mailing Address - Fax:916-991-7297
Practice Address - Street 1:851 OAK LN
Practice Address - Street 2:
Practice Address - City:RIO LINDA
Practice Address - State:CA
Practice Address - Zip Code:95673-2341
Practice Address - Country:US
Practice Address - Phone:916-991-6402
Practice Address - Fax:916-991-7297
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist