Provider Demographics
NPI:1871944314
Name:MINOR, RICHARD (RDH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MINOR
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 CRESTON PARK DR
Mailing Address - Street 2:SUITE NUMBER 2
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1113
Mailing Address - Country:US
Mailing Address - Phone:608-314-1940
Mailing Address - Fax:
Practice Address - Street 1:1344 CRESTON PARK DR
Practice Address - Street 2:SUITE NUMBER 2
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1113
Practice Address - Country:US
Practice Address - Phone:608-314-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11476124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist