Provider Demographics
NPI:1215053418
Name:BANKHEAD, RICHARD R (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:BANKHEAD
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 1:136 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2538
Mailing Address - Country:US
Mailing Address - Phone:617-332-1335
Mailing Address - Fax:
Practice Address - Street 1:1259 HYDE PARK AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-2817
Practice Address - Country:US
Practice Address - Phone:617-364-5500
Practice Address - Fax:617-361-1351
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA142551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice