Provider Demographics
NPI:1700890340
Name:RICHARDSON, DOUGLAS DENNIS SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:DENNIS
Last Name:RICHARDSON
Suffix:SR
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 1:2479 INDIAN WELLS TRL
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-9384
Mailing Address - Country:US
Mailing Address - Phone:937-262-2102
Mailing Address - Fax:937-267-5355
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:DENTAL (160)
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-262-2102
Practice Address - Fax:937-267-5355
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery