Healthcare Provider Details

I. General information

NPI: 1770085375
Provider Name (Legal Business Name): BEVAN RICHARDSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 OAK LN
RIO LINDA CA
95673-2341
US

IV. Provider business mailing address

851 OAK LN
RIO LINDA CA
95673-2341
US

V. Phone/Fax

Practice location:
  • Phone: 916-991-6402
  • Fax: 916-991-7297
Mailing address:
  • Phone: 916-991-6402
  • Fax: 916-991-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RENEE DAVIDSON
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 916-991-6402