Provider Demographics
NPI:1811015183
Name:RICHARDSON, JOHN F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:F
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 1:908 E MAIN ST
Mailing Address - Street 2:P.O. BOX 369
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-9782
Mailing Address - Country:US
Mailing Address - Phone:920-582-0688
Mailing Address - Fax:920-582-0692
Practice Address - Street 1:908 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986-9782
Practice Address - Country:US
Practice Address - Phone:920-582-0688
Practice Address - Fax:920-582-0692
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33473900Medicare ID - Type UnspecifiedEDS