Provider Demographics
NPI:1639179047
Name:STULTZ, RICHARD JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAY
Last Name:STULTZ
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 1:3900 N BAY DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3632
Mailing Address - Country:US
Mailing Address - Phone:262-639-1600
Mailing Address - Fax:
Practice Address - Street 1:3900 N BAY DR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3632
Practice Address - Country:US
Practice Address - Phone:262-639-1600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001078-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice