Provider Demographics
NPI:1386045532
Name:RICHARDSON, FAIN
Entity type:Individual
Prefix:
First Name:FAIN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 COUNTY ROAD 13
Mailing Address - Street 2:
Mailing Address - City:MEEKER
Mailing Address - State:CO
Mailing Address - Zip Code:81641-7719
Mailing Address - Country:US
Mailing Address - Phone:970-620-0060
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 622
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-0622
Practice Address - Country:US
Practice Address - Phone:970-620-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001010-14122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist