Provider Demographics
NPI:1205800729
Name:RICHARDSON, SHANTA DIANNE (DMD)
Entity type:Individual
Prefix:MRS
First Name:SHANTA
Middle Name:DIANNE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DMD
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Mailing Address - Street 1:8001 HILLSBOROUGH RD
Mailing Address - Street 2:SUITE L
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6876
Mailing Address - Country:US
Mailing Address - Phone:443-574-8944
Mailing Address - Fax:443-574-8947
Practice Address - Street 1:8001 HILLSBOROUGH RD
Practice Address - Street 2:SUITE L
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6876
Practice Address - Country:US
Practice Address - Phone:443-574-8944
Practice Address - Fax:443-574-8947
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA212081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0208469Medicaid