Healthcare Provider Details

I. General information

NPI: 1750425294
Provider Name (Legal Business Name): RICHARD CARLOS TATUM SR. D.D.S., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY SUITE 100
COLUMBIA MD
21044-3264
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY SUITE 100
COLUMBIA MD
21044-3264
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-8330
  • Fax: 410-992-4095
Mailing address:
  • Phone: 410-730-8330
  • Fax: 410-992-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number4224
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: