=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902184476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER BLAKE RICHARDSON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2011
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 W 2ND AVE
-----------------------------------------------------
City | CORSICANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-872-1661
-----------------------------------------------------
Fax | 903-872-5961
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 W 2ND AVE
-----------------------------------------------------
City | CORSICANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75110-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-872-1661
-----------------------------------------------------
Fax | 903-872-5961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 27274
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------