MEDICARE: DR. JOHN F. 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
1	122300000X	Dentist	2790	WI

General Provider Information

NPI Number	:	1811015183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN F. RICHARDSON D.D.S.

Provider Business Mailing Address
First Line	:	908 E MAIN ST
Second Line	:	P.O. BOX 369
City	:	WINNECONNE
State	:	WI
Zip	:	54986-9782
Country	:	US
Telephone Number	:	920-582-0688
Fax Number	:	920-582-0692

Provider Business Practice Location Address
First Line	:	908 E MAIN ST
Second Line	:
City	:	WINNECONNE
State	:	WI
Zip	:	54986-9782
Country	:	US
Telephone Number	:	920-582-0688
Fax Number	:	920-582-0692

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	01/18/2008

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