Provider Demographics
NPI:1760775845
Name:RICHARDSON, JEFFREY RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:RICHARDSON
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 1:3401 W ESPLANADE AVE S STE 2
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-3423
Mailing Address - Country:US
Mailing Address - Phone:504-301-3590
Mailing Address - Fax:504-301-9783
Practice Address - Street 1:3401 W ESPLANADE AVE S STE 2
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3423
Practice Address - Country:US
Practice Address - Phone:504-301-3590
Practice Address - Fax:504-301-9783
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1861677Medicaid