Healthcare Provider Details

I. General information

NPI: 1841249679
Provider Name (Legal Business Name): RICHARD A. FENTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1679 WOODMAN DR
DAYTON OH
45432-3336
US

IV. Provider business mailing address

61 SOUTH STATE STREET
PHILLIPSBURG OH
45354
US

V. Phone/Fax

Practice location:
  • Phone: 937-258-1515
  • Fax: 937-258-9790
Mailing address:
  • Phone: 937-884-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOH4100
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: