Provider Demographics
NPI:1730172263
Name:BOONE, RICHARD TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TODD
Last Name:BOONE
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 1:803 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7711
Mailing Address - Country:US
Mailing Address - Phone:580-332-3010
Mailing Address - Fax:580-332-1302
Practice Address - Street 1:803 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7711
Practice Address - Country:US
Practice Address - Phone:580-332-3010
Practice Address - Fax:580-332-1302
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100112550AMedicaid
OK787600OtherUNITED CONCORDIA
OK787600OtherUNITED CONCORDIA
OK100112550AMedicaid