Provider Demographics
NPI:1790826139
Name:RICHARDSON, BYRON L (DMD MS)
Entity type:Individual
Prefix:DR
First Name:BYRON
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 E RUTHERFORD RD
Mailing Address - Street 2:DR BYRON L RICHARDSON
Mailing Address - City:LANDRUM
Mailing Address - State:SC
Mailing Address - Zip Code:29356
Mailing Address - Country:US
Mailing Address - Phone:864-457-4161
Mailing Address - Fax:864-457-4162
Practice Address - Street 1:1000 E RUTHERFORD RD
Practice Address - Street 2:DR BYRON L RICHARDSON
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356
Practice Address - Country:US
Practice Address - Phone:864-457-4161
Practice Address - Fax:864-457-4162
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2294Medicaid
NC89066RYOtherMEDICAID