Provider Demographics
NPI:1801969514
Name:LESTAGE, RICHARD B (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:LESTAGE
Suffix:
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 1:99 EDGEWOOD RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28804-3575
Mailing Address - Country:US
Mailing Address - Phone:828-505-3410
Mailing Address - Fax:828-505-3405
Practice Address - Street 1:99 EDGEWOOD RD
Practice Address - Street 2:SUITE E
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-3575
Practice Address - Country:US
Practice Address - Phone:828-505-3410
Practice Address - Fax:828-505-3405
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79381223G0001X
VA0066981223G0001X
FLDN84591223G0001X
LA33021223G0001X
TNDS40981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
9029XOtherBLUE CROSS BLUE SHIELD NC
NC5905316Medicaid