Provider Demographics
NPI:1891884391
Name:PAGE, RICHARD LAMONTE (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LAMONTE
Last Name:PAGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MONTE
Other - Middle Name:
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3300 BEE CAVES RD STE 290
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6660
Mailing Address - Country:US
Mailing Address - Phone:512-327-2131
Mailing Address - Fax:
Practice Address - Street 1:3300 BEE CAVES RD
Practice Address - Street 2:290
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6600
Practice Address - Country:US
Practice Address - Phone:512-327-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36061223G0001X
TX28977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806402100Medicaid
ID412045602OtherDENTAL CORPORATION TIN