Healthcare Provider Details

I. General information

NPI: 1093772634
Provider Name (Legal Business Name): BRENDA RICHARDSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 S SALINA ST
SYRACUSE NY
13202-3536
US

IV. Provider business mailing address

251 SALINA MEADOWS PKWY SUITE 100
SYRACUSE NY
13212-4584
US

V. Phone/Fax

Practice location:
  • Phone: 315-476-7921
  • Fax: 315-474-1448
Mailing address:
  • Phone: 315-464-2096
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number048507
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: