Provider Demographics
NPI:1578683876
Name:ROY W. RICHARDSON, III, D.D.S., P.A.
Entity Type:Organization
Organization Name:ROY W. RICHARDSON, III, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:WILKINS
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-289-4505
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
113590OtherUNITED CONCORDIA