Provider Demographics
NPI:1912065020
Name:RICHARDSON, RANDELL
Entity type:Individual
Prefix:
First Name:RANDELL
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 1:650 INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-6612
Mailing Address - Country:US
Mailing Address - Phone:972-221-2220
Mailing Address - Fax:
Practice Address - Street 1:1288 W MAIN ST
Practice Address - Street 2:SUITE 123
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3420
Practice Address - Country:US
Practice Address - Phone:972-221-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice