Provider Demographics
NPI:1790803161
Name:RICHARDSON, MARY LOU (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 MAYFAIR DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3072
Mailing Address - Country:US
Mailing Address - Phone:252-443-4308
Mailing Address - Fax:
Practice Address - Street 1:216 MAYFAIR DR
Practice Address - Street 2:
Practice Address - City:ROCKY MT
Practice Address - State:NC
Practice Address - Zip Code:27804-3072
Practice Address - Country:US
Practice Address - Phone:252-443-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC63761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice