Healthcare Provider Details

I. General information

NPI: 1134799935
Provider Name (Legal Business Name): KORI MARIE RICHARDSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KORI MARIE MILLER RDH

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57250 ALPHA DR
GOSHEN IN
46528-7804
US

IV. Provider business mailing address

50782 COBBLESTONE DR
GRANGER IN
46530-1309
US

V. Phone/Fax

Practice location:
  • Phone: 574-875-3817
  • Fax:
Mailing address:
  • Phone: 574-220-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13008766A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: