Healthcare Provider Details

I. General information

NPI: 1538227582
Provider Name (Legal Business Name): RICHARD D PUTNAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5892 MAIN ST STE 4
SPRINGFIELD OR
97478-5496
US

IV. Provider business mailing address

5892 MAIN ST STE 4
SPRINGFIELD OR
97478-5496
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-8816
  • Fax: 541-741-8176
Mailing address:
  • Phone: 541-726-8816
  • Fax: 541-741-8176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4861
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: