Provider Demographics
NPI:1811990880
Name:OMOHUNDRO, RICHARD M (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:OMOHUNDRO
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 1:1311 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-2276
Mailing Address - Country:US
Mailing Address - Phone:573-642-5075
Mailing Address - Fax:
Practice Address - Street 1:214 E 2ND ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1650
Practice Address - Country:US
Practice Address - Phone:573-642-6624
Practice Address - Fax:573-642-6210
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice