Provider Demographics
NPI:1790973618
Name:MCDONALD, RICHARD THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
Last Name:MCDONALD
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 1:35 S JOHNSON ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1658
Mailing Address - Country:US
Mailing Address - Phone:248-333-2424
Mailing Address - Fax:248-623-1252
Practice Address - Street 1:35 S JOHNSON ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1658
Practice Address - Country:US
Practice Address - Phone:248-333-2424
Practice Address - Fax:248-623-1252
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010078921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2810761Medicaid