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General NPI Number Information
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NPI Number | 1033735089
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Entity Type | Individual
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Provider Name | TREVOR DANIEL RICHMOND DMD
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Gender | Male
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Dates
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Enumeration Date | 06/24/2020
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Last Update Date | 08/09/2024
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Provider Practice Location Address
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Address Line | 11825 N KNOXVILLE AVE
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City | DUNLAP
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State | IL
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Zip | 61525-8842
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Country | US
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Telephone | 309-740-3901
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Fax |
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Provider Business Mailing Address
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Address Line | 7713 S STRANZ RD
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City | MAPLETON
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State | IL
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Zip | 61547-9412
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Country | US
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Telephone | 309-431-1512
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021.003328
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.032728
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License Number State | IL
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