Provider Demographics
NPI:1629166889
Name:RICHARDSON, JR., JAMES M (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:RICHARDSON, JR.
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-4400
Mailing Address - Country:US
Mailing Address - Phone:843-374-8010
Mailing Address - Fax:843-374-2030
Practice Address - Street 1:804 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-4400
Practice Address - Country:US
Practice Address - Phone:843-374-8010
Practice Address - Fax:843-374-2030
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2547122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2547Medicaid