Provider Demographics
NPI:1598848160
Name:COTTRELL, RICHARD W (D D S P C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:COTTRELL
Suffix:
Gender:M
Credentials:D D S P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11060 SMILE WAY
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-3470
Mailing Address - Country:US
Mailing Address - Phone:540-775-7671
Mailing Address - Fax:540-775-0626
Practice Address - Street 1:11060 SMILE WAY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-3470
Practice Address - Country:US
Practice Address - Phone:540-775-7671
Practice Address - Fax:540-775-0626
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010088551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA978187OtherUNITED CONCORDIA