Healthcare Provider Details

I. General information

NPI: 1972733566
Provider Name (Legal Business Name): RICHARDSON CENTER FOR ORAL & FACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6865 DEERPATH RD DORSEY STATION, SUITE 302
ELKRIDGE MD
21075-6257
US

IV. Provider business mailing address

6865 DEERPATH RD DORSEY STATION, SUITE 302
ELKRIDGE MD
21075-6257
US

V. Phone/Fax

Practice location:
  • Phone: 410-796-3333
  • Fax: 410-796-3375
Mailing address:
  • Phone: 410-796-3333
  • Fax: 410-796-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD0067181
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14259
License Number StateMD

VIII. Authorized Official

Name: DR. DANIEL T RICHARDSON
Title or Position: OWNER
Credential: MD, DMD
Phone: 410-796-3333