Provider Demographics
NPI:1922263607
Name:USEDOM, RICHARD KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KEITH
Last Name:USEDOM
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 1:6050 BRYNWOOD DR STE 106
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6579
Mailing Address - Country:US
Mailing Address - Phone:815-877-3565
Mailing Address - Fax:
Practice Address - Street 1:6050 BRYNWOOD DR STE 106
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6579
Practice Address - Country:US
Practice Address - Phone:815-877-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018382122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist