Basic Information
| Provider Information | |||||||||
| NPI: | 1982765319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVORAK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548803709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153921955 | ||||||||
| FaxNumber: | 7153921935 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CARLTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557187703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183363524 | ||||||||
| FaxNumber: | 2183849002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D10709 | MN | Y | Dental Providers | Dentist | General Practice |
No ID Information.