Healthcare Provider Details

I. General information

NPI: 1114610201
Provider Name (Legal Business Name): CODY RICHARDSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S DETROIT ST
LAGRANGE IN
46761-2314
US

IV. Provider business mailing address

7075 N 850 E
HOWE IN
46746-9598
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12014117A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: