Provider Demographics
NPI:1912903444
Name:TAVERNA, RICHARD DOUGLAS (PHD,DDS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DOUGLAS
Last Name:TAVERNA
Suffix:
Gender:M
Credentials:PHD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W.LOOP 1604 NORTH, SUITE 109
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251
Mailing Address - Country:US
Mailing Address - Phone:210-647-7447
Mailing Address - Fax:210-647-7839
Practice Address - Street 1:430 W LOOP 1604 N
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3342
Practice Address - Country:US
Practice Address - Phone:210-469-3869
Practice Address - Fax:210-402-0025
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-09-12
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TX136961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice