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NPI Code Detail

MEDICARE: BRUCE W RICHARDSON D.D.S.

MEDICARE: BRUCE W RICHARDSON D.D.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223P0300XPeriodonticsD3443PEID

General Provider Information

NPI Number : 1306959424
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRUCE W RICHARDSON D.D.S.
Provider Business Mailing Address
First Line : 3171 W DEERFIELD CT
Second Line :
City : EAGLE
State : ID
Zip : 83616-2343
Country : US
Telephone Number : 208-841-9009
Fax Number :
Provider Business Practice Location Address
First Line : 317 W CHERRY LN
Second Line :
City : MERIDIAN
State : ID
Zip : 83642-1608
Country : US
Telephone Number : 208-888-2055
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/15/2006
Last Update Date : 07/08/2007

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