Provider Demographics
NPI:1790984896
Name:STANDAGE, RICHARD WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:STANDAGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 FRANKLIN BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7708
Mailing Address - Country:US
Mailing Address - Phone:480-828-7707
Mailing Address - Fax:
Practice Address - Street 1:BLDG 128 CHAFFEE RD.
Practice Address - Street 2:FORT BLISS DENTAC
Practice Address - City:FT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-742-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7295122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist