MEDICARE: DR. RUSSELL T RICHARDSON DMD

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	1223G0001X	General Practice Dentistry	DN17561	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN17561	OTHER	FL	MEDICAL LISCENSE #

General Provider Information

NPI Number	:	1871705335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL T RICHARDSON DMD

Provider Business Mailing Address
First Line	:	17350 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-6039
Country	:	US
Telephone Number	:	850-230-3364
Fax Number	:	850-233-9434

Provider Business Practice Location Address
First Line	:	17350 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-6039
Country	:	US
Telephone Number	:	850-230-3364
Fax Number	:	850-233-9434

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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