Provider Demographics
NPI:1205921921
Name:RICHARDSON, WYATT L (DDS)
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 BONNIEBANK ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234-6601
Mailing Address - Country:US
Mailing Address - Phone:804-271-1443
Mailing Address - Fax:
Practice Address - Street 1:4225 BONNIEBANK ROAD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-6601
Practice Address - Country:US
Practice Address - Phone:804-271-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010037731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice