Provider Demographics
NPI:1265551089
Name:POWELL, RICHARD STEWART (DMD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:STEWART
Last Name:POWELL
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 1:23851 LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-8218
Mailing Address - Country:US
Mailing Address - Phone:530-268-9769
Mailing Address - Fax:
Practice Address - Street 1:10044 WOLF RD
Practice Address - Street 2:SUITE D
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949-8193
Practice Address - Country:US
Practice Address - Phone:530-268-9769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA215001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9384501Medicaid