Provider Demographics
NPI:1821194689
Name:RICHARDSON, THOMAS LANE (DMD JD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LANE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DMD JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 FOREST AVENUE
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1884
Mailing Address - Country:US
Mailing Address - Phone:202-878-3480
Mailing Address - Fax:202-878-3481
Practice Address - Street 1:1250 FOREST AVENUE
Practice Address - Street 2:SUITE 3B
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1884
Practice Address - Country:US
Practice Address - Phone:202-878-3480
Practice Address - Fax:202-878-3481
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME32281223G0001X
AK5171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice