Provider Demographics
NPI:1821424110
Name:RICHARDSON, WILLIE J (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:J
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 1:5418 PARK HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4645
Mailing Address - Country:US
Mailing Address - Phone:410-542-6900
Mailing Address - Fax:410-542-6707
Practice Address - Street 1:5418 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4645
Practice Address - Country:US
Practice Address - Phone:410-542-6900
Practice Address - Fax:410-542-6707
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist