Healthcare Provider Details

I. General information

NPI: 1790984896
Provider Name (Legal Business Name): RICHARD WILLIAM STANDAGE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 128 CHAFFEE RD. FORT BLISS DENTAC
FT BLISS TX
79916
US

IV. Provider business mailing address

1255 FRANKLIN BLUFF DR
EL PASO TX
79912-7708
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-6001
  • Fax:
Mailing address:
  • Phone: 480-828-7707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7295
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7295
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: