Healthcare Provider Details

I. General information

NPI: 1366474983
Provider Name (Legal Business Name): RICHARD TODD CRIST D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 05/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S MAIN ST
MADISONVILLE KY
42431-3342
US

IV. Provider business mailing address

1340 S MAIN ST
MADISONVILLE KY
42431-3342
US

V. Phone/Fax

Practice location:
  • Phone: 270-825-0676
  • Fax: 270-825-0696
Mailing address:
  • Phone: 270-825-0676
  • Fax: 270-825-0696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8199
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8199
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: