Provider Demographics
NPI:1376632448
Name:RICHARDSON, DOROTHY JEAN
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:JEAN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21818 COUNTY ROAD 312
Mailing Address - Street 2:
Mailing Address - City:CLARKTON
Mailing Address - State:MO
Mailing Address - Zip Code:63837-8197
Mailing Address - Country:US
Mailing Address - Phone:573-448-3460
Mailing Address - Fax:
Practice Address - Street 1:1617 N MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3445
Practice Address - Country:US
Practice Address - Phone:573-778-3042
Practice Address - Fax:573-778-9432
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant