Provider Demographics
NPI:1699956565
Name:RICHARDSON, DONNIE JOE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:DONNIE
Middle Name:JOE
Last Name:RICHARDSON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516A LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2226
Mailing Address - Country:US
Mailing Address - Phone:662-328-8001
Mailing Address - Fax:888-852-8644
Practice Address - Street 1:516A LINCOLN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2226
Practice Address - Country:US
Practice Address - Phone:662-328-8001
Practice Address - Fax:888-852-8644
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3463-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02150825Medicaid