Provider Demographics
NPI:1760053367
Name:RICHARDSON, GARRETT GLEN (IPDH)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:GLEN
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:IPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 PEASE RD
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ME
Mailing Address - Zip Code:04093-6522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2693
Practice Address - Country:US
Practice Address - Phone:207-221-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2747124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist