Provider Demographics
NPI:1619371333
Name:SPARKS, RICHARD GLEN (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GLEN
Last Name:SPARKS
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 1:320 E MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4321
Mailing Address - Country:US
Mailing Address - Phone:281-461-3368
Mailing Address - Fax:281-461-3369
Practice Address - Street 1:320 E MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4321
Practice Address - Country:US
Practice Address - Phone:281-461-3368
Practice Address - Fax:281-461-3369
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist