Provider Demographics
NPI:1932243094
Name:VANDIVER, RICHARD C (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:VANDIVER
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 1:2125 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:UNIT #3
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5314
Mailing Address - Country:US
Mailing Address - Phone:318-349-1909
Mailing Address - Fax:
Practice Address - Street 1:1625 DAVID RAINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5899
Practice Address - Country:US
Practice Address - Phone:318-841-6048
Practice Address - Fax:318-841-6044
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA20409OtherCDS #
LA4538OtherSTATE BOARD LICENSE
LABC3272983OtherDEA NUMBER