Healthcare Provider Details

I. General information

NPI: 1659584670
Provider Name (Legal Business Name): DAVID W RICHARDS, DDS, PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 4TH AVE SUITE 303
SAN DIEGO CA
92103-2116
US

IV. Provider business mailing address

4060 4TH AVE SUITE 303
SAN DIEGO CA
92103-2116
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-0905
  • Fax: 619-543-0422
Mailing address:
  • Phone: 619-543-0905
  • Fax: 619-543-0422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number39876
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID W RICHARDS
Title or Position: OWNER
Credential: DDS
Phone: 619-543-0905