=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407860810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP DAVID RICHARDSON RDH, DOM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 ENCINO PLACE NE SUITE 7
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-843-9636
-----------------------------------------------------
Fax | 505-843-6277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 717 ENCINO PLACE NE SUITE 7
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-843-9636
-----------------------------------------------------
Fax | 505-843-6277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 800
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------