Provider Demographics
NPI:1134799935
Name:RICHARDSON, KORI MARIE (RDH)
Entity type:Individual
Prefix:
First Name:KORI
Middle Name:MARIE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KORI
Other - Middle Name:MARIE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:50782 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1309
Mailing Address - Country:US
Mailing Address - Phone:574-220-2859
Mailing Address - Fax:
Practice Address - Street 1:57250 ALPHA DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7804
Practice Address - Country:US
Practice Address - Phone:574-875-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13008766A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN13008766AOtherDENTAL HYGIENE LICENSE NUMBER