Provider Demographics
NPI:1710096706
Name:TATUM, RICHARD C JR (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:TATUM
Suffix:JR
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 1:3008 E. BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2672
Mailing Address - Fax:928-283-2991
Practice Address - Street 1:167 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2672
Practice Address - Fax:928-283-2991
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127541223G0001X
AZD66721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ888927Medicaid