Provider Demographics
NPI:1841366754
Name:MEDICO, RICHARD D (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:MEDICO
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 1:171 S ROCKINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-3723
Mailing Address - Country:US
Mailing Address - Phone:716-688-8431
Mailing Address - Fax:
Practice Address - Street 1:5755 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-2357
Practice Address - Country:US
Practice Address - Phone:716-683-0891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051679-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02733159Medicaid