Provider Demographics
NPI:1063548360
Name:DEFURIO, RICHARD L (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:DEFURIO
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 1:2601 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2865
Mailing Address - Country:US
Mailing Address - Phone:262-632-3156
Mailing Address - Fax:262-632-3063
Practice Address - Street 1:2601 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2865
Practice Address - Country:US
Practice Address - Phone:262-632-3156
Practice Address - Fax:262-632-3063
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice