Healthcare Provider Details

I. General information

NPI: 1699708248
Provider Name (Legal Business Name): RICHARD JOSEPH POUPARD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 MERLIN CT
MIDLAND MI
48640-7358
US

IV. Provider business mailing address

6112 MERLIN CT
MIDLAND MI
48640-7358
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-9979
  • Fax: 989-839-9553
Mailing address:
  • Phone: 989-839-9979
  • Fax: 989-839-9553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberRP016402
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberRP016402
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: