Provider Demographics
NPI:1881001097
Name:THIBODEAU, RICHARD LEWIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEWIS
Last Name:THIBODEAU
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 1:5356 CORTEZ CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5823
Mailing Address - Country:US
Mailing Address - Phone:239-410-8832
Mailing Address - Fax:
Practice Address - Street 1:5356 CORTEZ CT
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5823
Practice Address - Country:US
Practice Address - Phone:239-410-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-20
Last Update Date:2014-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist